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0643''coa' 19:38 -.145714239 PARKS AND RECREATION F'A:ii <br />• ' �. ^v 5 • • <br />/;/— a o07-060 <br />I Robert A. Acosta, President hereby affirm under penalty of perjury. the <br />(Neme)Tsoe) <br />following declaration <br />I certify on behah of Acosta A_ ss "t s that during the term of my <br />(Otpounm Nu c) <br />c mtract witb North Amaricgn emanrc Inc dba5hamrxk Shaws. City of Santa <br />P.na, I will not employ any person in any naanuer so as to become subject to the workers' <br />compensation laws of California, and agree that if I should become subject to the <br />workers' compensation provisions of Section 3700 of the Labor Code, I shat: iortbwith <br />C ornpl.y with those provisions. <br />DATE; _� /3 CL_. <br />By: <br />Name: <br />Title: <br />v <br />WARNING' FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />k D CTV IL FINES UP TO ONE HlT1DRBD THOUSAND DOLLARS (5100,000). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />Ii\ SECTION 3706 OF THE LABOR CODE, INTEREST, ARID ATTORNEY'S FEES. <br />