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<br />WORKERS' COMPENSATION DECLARATION <br /> <br /> <br />,,- ereby affirm under penalty of perjury, the <br /> <br /> <br />, City of Santa Ana, I will not <br /> <br />employ any person in any manner so as to bec me subject to the workers' compensation <br /> <br />laws of Cali fomi a, and agree that in should become subject to the workers' <br /> <br />compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply <br /> <br />with those provisions. <br /> <br />DATE: l' 1.~4y <br />( <br /> <br />By: ~t... '~& <br />Name: 6; ~/~ A /'E?!7 <br />Title: C) U/ P ,!.'?{ <br />Telephone: f7('y 7'P?:3 7? 2.. <br /> <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENAL TIES <br />AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br /> <br />~7 <br /> <br />, <br /> <br />