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Hov 09 05 10:11a Parking Design Group, LLP 919-990-0494 p.2 <br />I hereby affiml under penalty of perjury, the following dmaration: <br />I certify that during the term of my contract with the <br />9 City of Santa Ana, I will not employ any person in any manner so <br />as to become subject to the workers' compensation laws of California, and agree that if I should <br />become subject to the workers' compensation provisions of Section 3700 of the Labor Code,1 shall <br />forthwith comply with those provisions. <br />DATE: IJ /9 %0 - <br />By- zz� l± . P.� <br />Name: QAWO L. ✓0411- <br />Title- PA RT rJB1Q - PA491.U4 0"14 I 61auF] ct-0 <br />Telephone: S!8 — Is / - 2-1 Z 'T <br />WARNING-. FAILURE TO SECURE WORYSERVCOMEPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND <br />CIVIL FINES UP TO ONE HUNDRFI) THOUSAND DOLLARS (S 100,000). IN ADDITION <br />TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 <br />OF THE LA]BOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />1.i rliK)vria� AS 'ro h'oltM <br />Stt SSi.;,e� <br />i24 Atlor;cy <br />