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<br />N_2006-068 <br /> <br />WORKERS' COMPENSATION DECLARATION <br /> <br /> <br />Jt/i'!/( ~M Z hereby affirm under penalty ofpcrjury, the <br />(;..lam<;:/Tille:) <br />following declaration: <br /> <br />I certify on bchalfof CrtJf-tl/.sp'>/1/J that during the term of my <br />(Organization Name) (,/ <br /> <br />contract with the <br /> <br />, City of Santa Ana, I will not <br /> <br />employ any person in any manner so as to become subject to the workers' compensation <br /> <br />laws of Cahfomia, and agree that if! should bccomc subject to the workers' <br /> <br />compensation provisions of Section 3700 ofthe Labor Code, 1 shall forthwIth comply <br /> <br /> <br />DATE: <br /> <br />f2-zF2> <br /> <br />By: Cr d/ a /$ c(J,e f/1/] <br />'/. Y <br />Name: ~ /lVI c~ 5<'9E#Z- <br /> <br />Title:fi5/?n #/pc/#a/ <br /><./ . <br />Telephone: (7/'I) 'f J?~ I YV 2---- <br />/ <br /> <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />U'-JLAWFUL, AKD SHALL SUBJECT AN EMPLOYER TO CRIMIKAL PENALTIES <br />AND CIVIL FP.-lES CP 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, I'-JTEREST, AND ATTORNEY'S FEES. <br />