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<br />Jan 1~ 0.. 0'4:09p <br /> <br />T 1 1 at; 1 <br /> <br />p.l <br /> <br />o/QßKERS' COMPENSA nON DECLA~:rION <br /> <br /> <br />I ~/>oJETH :r~.f'el'~by aŒrm Wider penalty of perjury, the <br />(N.....n'lCk) a"";>./'JEt: <br />following declar:nion : <br /> <br />--- ~ ¿;; <br />l ccnify on behalf of /0< Ee/t:'o:s. r*~;h4hat dUriL1g the tenn of my <br /> <br />(Or¡:"'''!lIìal1 Name) <br /> <br />contract with the <br /> <br />, City of Santa Ana, 1 will nut <br /> <br />employ :my person in any manncr so as to bccome subject to the workers' compensation <br /> <br />taws of California, and agree thai if I should become :subject tu the wurker~' <br /> <br />compensation provisions of Section 3700 oflhe Lab<>r Code. I shall forthwith comply <br /> <br />witl1 those provisions. <br />DATE: 01- /¥'" 2CX":'> 1:1- <br /> <br />By: ~ / L"-e;.J'4'.r~ <br />Name: K:r- '~é!?'/(:"ð <br /> <br />Title <br /> <br />OU-:JNEe. <br />/N/' ¿;,.3? ~ 07f/'? <br /> <br />Telephone: <br /> <br />.._-_..~...,.._~ <br /> <br />W ARN(NG: P AlLURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLA WFUL. AND SHALL SUBJECr AN EMPLOYER TO CRIMfNAL PENALTIES <br />AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (SI00,000). IN <br />AODlTlON TO THE COST OF COMPENSATION. DAMAGES AS PROVlDEO !-'OR <br />rN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br /> <br />7tJ~Ld-~1 2/3 <br /> <br />I <br /> <br />{ . d <br /> <br />tr9L9-9E9- t,¡ L <br /> <br />oot..laIol ua) <br /> <br />d2s:eo trO tr! uer <br />