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<br />Brod\.l <br />Jun, II 02 01.12p <br /> <br />7146690464 <br /> <br />06/11/02 0Z10SP P.00Z <br /> <br />WORKIlRS' COMPENSATION DECI '-RATION <br /> <br />j",.lJ vs"1J)"3 t I.. '''~by alTinn uncleT penllty of pctjury, the <br />~) r <br />(oil owing declaration : <br />I ccnify 011 bdWf of ~,...~..~ that during the term of my <br />C<<Ittaf:t willi !be '1, ..../!.e, G---s o.r-:- . . City of SIllIa Ana, I willllClt <br />employ any penon in any manDel' so as to become subj<<t to the workers' COIllI'C..""lion <br /> <br />laws or c.Jjfomia,11Id qnllllblr if I shoaId ~ _me SDbjoI:t to the "Oih..~' <br />CompenAltion JIlOVisions of Section 3700 of the Labor Code. I nil forth with comply <br /> <br />with. those provisions. <br />DATE: C/,jot. <br /> <br />By: L/:../A' ~ <br />NlUIIC: lOci cI {!. ,/\)~ <br />Tille: {J, I~r t.;p,....! <br />Telephone: ?1'r'~bG'S-9 ;1" <br /> <br />WARNlNG: FAD..URB TO SECURB WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT ANEMPLO'YER TO CRIMINAL PENALTIES <br />AND ClVR. FINES UP TO ONE HUNDRED THOUSAND DOlLARS (SJOO,OOO). IN <br />ADDmON TO nm COST OF COMPENSA 11ON, DAMAGES AS PROVIDED FOR <br />IN SECl'ION 3706 OP THE LABOR CODB.INTEREST, AND ATrORNBY'S PEa. <br /> <br /> <br />CR INE LEE SHAW <br />Deputy City Attorney <br /> <br />p.2 <br />