Laserfiche WebLink
FROM : Bay Area Driving School PHONE NO. : 510 B56 4408 Jun. 05 2007 06:52PM P2 <br />WORKERS' COMPENSATION DECLARATION <br />/P&IN6, <br />I ERIKA VU Y,N A15iRuc 1DR hereby affirm under penalty of perjury, the <br />(NamPlTitie) <br />following declaration <br />SARTY D,PI vE,I''S ED , LG c <br />I certify on behalf of BA` hwtn URWIN(r SCHov that during the term of my <br />(Organization Name) <br />contract with the DNf INE D�'�VER'd ,(r6 , City of Santa Ana, I will not <br />employ any person in any manner so as to become subject to the workers' compensation <br />laws of California, and agree that if 1 should become subject to the workers' <br />compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply <br />with those provisions. <br />DATE: 2' <br />W3 <br />Name: MK4 VORP — <br />Title: ORIYINF SN5rleit6%4%e <br />Telephone: �i10 - 537 -1757 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGI? 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 />-N SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />APPROVED AS TO FORM <br />LaLteSi.,;cJ <br />Assistaat City Attorrxv <br />