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<br />. . <br /> <br />Hf?Uil et:f:" P.,~ckrll-'d <br /> <br />103 <br /> <br />" ., <br />. . L <br /> <br />WORKERS' COMPENSATION DECLARATION <br /> <br />I :f~Coc:.f', P.t<r-JC(f'f\"l.- hereby affinn under penalty of perjury, the <br />(Nametr,Ue) <br />following declaration: <br /> <br />I certify on behalf of 1C'fPU>1.E: f(UAX-l\?-)$ that during the tenn of my <br />(Organizalion Name) <br />contract with the ,::."""" ........~,~ \)L...... AjI!M-'-t 1-' City of Santa Ana and the <br /> <br />Community Redevelopment Agency, I will not employ any person in any manner so as to <br /> <br />become subject to the workers' compensation laws of California, and agree that if! <br /> <br />should become subject to the workers' compensation provisions of Section 3700 of the <br /> <br />r.b<>' COd'. I "-II """'wiili ,=ply wi'" "'000 pro'i'iO~ <br />DATE: \0/1\10"2.. <br /> <br />By: ~U?L-6 <br />N arne: 'T&"C;C: c.o tE- ~(Z.o P\1t.l1 o1J c; <br />Title: -p.e., tJc.-lf'A'\.. <br />Telephone: b I 'i ') S1 '-/- )010 <br /> <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 A nORNEY'S FEES. <br /> <br />APPROVED AS TO FORM <br /> <br />~r <br />..... ~^.fl () r:h I <br />Uiurn n.Y / <br />OopU\)' tit)' A\lllflley <br />