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<br />WORKERS' COMPENSATION DECLARATION <br /> <br />I Qc0.-.L, oj. Ty~ hereby affinn under penalty of perjury, the <br />(Nametritle) <br />following declaration: <br /> <br />I certify on behalf of r.1,.p,m~ j. 1-<' ,,,,,,- that during the tenn of my <br />(Organization Name) <br />contract with the ?L~"Nl'''' l' hI'" ",,"" 4.-'''-j' 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 California, and agree that if I should become subject to the workers' <br /> <br />compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply <br /> <br />with those provisions. <br /> <br />DATE: <br /> <br />, \ J'Ll'> Jel.,. <br /> <br />,....... <br /> <br />By: \ ~d't \ 0' \ -;r , ____ <br />n C...-J -=-. '; <br />Name: Kt,p,~) r -.I, T"1~L- <br /> <br />Title: \/i.1.,^,,( \ P r....C <br /> <br />Telephone: C{ 0/1' 04-2. !t-tyzS- <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 ATTORNEY'S FEES. <br /> <br />