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<br />-, , <br /> <br />. <br /> <br />WORKERS' COMPENSATION n~CLARATION <br /> <br />I L., ;:qq. 1 ~~icl0 hereby affmn under penalty of petjury, the <br />. (NameIJ'itle). ' <br />following declaration: . <br /> <br />I certify on behalf' of ~ e..l~ <br />(I (OiJani;oltjon Naml:l)' <br />contraCt with the 1.. t'\.o:kvrrc.{; Y"l, Jf rv I (.(?,J <br /> <br />that during the term of my , <br />, City of Santa Ana, I will not <br /> <br />employ any person in any manner so as to become subject to the workers' coxnpensation <br /> <br />, ' <br /> <br />laws of Californiat and agree :that if! should become subject to the workers' <br />compensation provisions ~fS~tion 3700 of the Lah?r Code, I shall forthwith comply <br />with those provisions. . <br />DATE: ,-:7/j/tJ6 <br /> <br />TeJ;;~ <br /> <br />By:;;imlt> K ~ <br />Name: L,rd-w K LcNuJ <br />Title:p-bt!-. <br />Telephone: :SID ,c/ ;y <7 Ol S) I <br /> <br />W ARNINO: FAILURE to SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUB.TECT AN EMPLOYER TO cRIMINAL PENALTIES <br />AND CIVIL FINES VI? TO ONE HUNDRED THOUSAND DOLLARS ($1'00,000). IN ' <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST. AND ~TTORNEY~.S FEES. <br />