Laserfiche WebLink
9 -000 ~ -- /3 ~ <br />WORKERS' COMPENSATION DECLARATION <br />I v~ _i~i~%~,~~Gyl~creby aff rm under penalty of pert ury> tie <br />(Nsmc/Titlc) <br />following declaration <br />Telephone: ~~~-'~/ - ~~ (o ~ J <br />i certify on behalf o~_g~~a that during the to f my <br />(U m7auon NOmc) mays ~O ~/~`~~~~~~5 <br />contract with the~~-°~~o / . Cify 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 i 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: ~u ~ /S~Q?_C~O~ <br />B <br />N <br />~7 ~ ~ <br />r f V %~ <br />~, <br />y / ~~ ~-t~ ~~ ~ys To <br />rJCil~u~~ GS S-'?J- <br />a ~: <br />itle: 1A~~~~ <br />T <br />WARNING: FAILURE TO SECURE WORKERS' COMf~ENSATION COVERAGE IS <br />UNLAWFUL, AND Si-IAJ,,L SUBJECT AN ENIPI,OY~R TO CRIMINAL PENALTIES <br />AND CIVIL NINES UP TO ONE T-1UNDRED THOUSAND DOLLARS ($100,000). IN <br />ADDITION TO TIIE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SF.,CTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES_ <br />