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WORKERS' COMPENSATION DECLARATION <br />I Suzanne Gatti, Vice President and Secretary, hereby affirm under penalty of <br />(Name/Title) <br />perjury, the following declaration <br />I certify on behalf of KOO Developments, Inc. that during the term of my <br />(Organization Name) <br />contract with the Public Works Agency, City of Santa Ana, I will not employ any person <br />in any manner so as to become subject to the workers' compensation laws of California, <br />and agree that if I should become subject to the workers' compensation provisions of <br />Section 3700 of the Labor Code, I shall forthwith comply with those provisions. <br />DATE: Apri14, 2008 <br />By: KOO Developments, Inc., a California corporation <br />f-~ - <br />~~:~,,. ~ r ~~~-~ <br />By: ~' <br />Suzanne Gatti, Vice President and Secretary <br />Telephone: (310 200-2151 <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 />~'~~ <br />