Laserfiche WebLink
N - -2,OD-7 - ilk <br />WORKERS' COMPENSATION DECLARATION <br />I Suzanne Gatti Vice President and Secreta hereby affirm under penalty of <br />(Name!Ti[le) <br />perjury, the following declaration : <br />I certify on behalf of KOO Developments, Inc. that during the term of my <br />(Organization Named p y y Person <br />contract with the Public Works Agency, City of Santa Ana, I will not em to an <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: Apri�_�14 2008 <br />By: KOO Developments, Inc., a California corporation <br />By: �t <br />Suzanne Gatti, Vice President and Secretary <br />Telephone: (3 10) 200-21 5 1 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />CT AN EMPLOYER TO CRIMINAL PENALTIES <br />UNLAWFUL, AND SHALL SUBJE <br />AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN <br />IADITION TO THE N SOECTIION 33706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'SDFE S. <br />