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WORKERS' COMPENSATION DECLARATION <br />I S�y, rhMHereby affirm under penalty of perjury, the <br />(Namerritle) <br />following declaration <br />I certify on behalf of that during the term of my <br />(Organization Name) <br />contract with the Cfonia Ann. & City of Santa Ana, I will not <br />employ any person in any manner so as to become subject to the workers' compensation <br />laws of California, and agree that if I should become subject to the workers' <br />compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply <br />with those provisions. <br />DATE: ' �l 05 <br />By: c Yfl D d I (C 7J <br />Name: KY I S o V-1 J r sYtur, Dyr; l <br />Title: Ve f-uY icL rt o� n <br />Telephone:Ogq) <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <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 />Tkilvc.0 AS 'fO FORM <br />../-r <br />/-'St <br />Stat Sheen <br />...0 <.ity Attorney <br />