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<br />..~."'.... <br />r-('II(~' " <br /> <br />. . <br /> <br />FAX NO. : 714-647-6549 <br /> <br />141003/005 <br />~r. 23 2æ3 æ:B7PM P2 <br /> <br />10/04/2004 MON 10:25 FAX 714+565 4020 CITY OF SANTA ANA <br /> <br />WORKERS' COMPENSATION DECLARATtON <br /> <br />I hereby affirm under penalty of perjury, the fo1l0win~ declafatioD: <br /> <br />I certify that during the term or my contract with the. <br />, City or Santa Ana, I will not employ any persoD in any <br />. manner so as to beeome subject'to the workers. compensation laws of California, and <br />agree that jf I should become subject to the workers' compensation provisions of Section <br />3700 of the Labor Code, I shall fonbwith co th those isi s. <br /> <br />DATE: 1j;;.itJ<! <br /> <br /> <br />By: -# 4'. /? <br /> <br />Name: ;f? /c;,,¿:.. iJ.:¡.,?ëY.5,ðIV <br /> <br />Title: I:'?W//er <br />TelePhone(-7/~.?~7- r7~q <br /> <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND,SHALL SUBJECT AN EMPLOYER TO ~AL PENALTIES <br />AND CIVn.. FINES UP TO ONE HUNDJŒD THOUSAND DOLLARS ($100,000). IN <br />ADDmON TO THE COST OF COMPENSATION, DAMAGES AS PROVmED FOR <br />IN SECTION 3106 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br /> <br />t <br />! <br /> <br />~ <br /> <br />l),...-''::>''''';'' ~i.. <br />