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WORKERS' COMPENSATION DECLARATION <br />I /~,!/,'//,'p F /~__~4~On~-S'_ hereby affirm under penalty of perjury, the <br />(Name(ritle) <br />following declaration <br />I certify on behalf of ~~+~/hp ~ • /~'PS D /s(S that during the term of my <br />(Ocgan~zation Name) <br />contract with the fb~icE' trn/T ,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: ~ S ~~ ~~ 8 <br />Name: ~/~+~1/:D ~ ~~F'~D/fS <br />Title: <br />Telephone: ZD(c-697-//y~$ <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 />