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WORKERS' COMPENSATION DECLARATION <br />I (.�o.� 5� ti �r hereby affirm under penalty of perjury, the <br />(Na /Title) Qii� 5 <br />following declaration : <br />I certify on behalf of C - C that during the term of my <br />yOrganization Narnel <br />contract with the R t z�5 �% , t r_ t a�" ..% , 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 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: N, c i a, c 1 <br />By: <br />Name: <br />Title: 4 S .c� vl7( <br />Telephone: <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 />