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<br />N,",~'D0<6-0'l'7 <br /> <br />WORKERS' COMPENSATION DECLARATION <br /> <br />I Gary Johnson, CEO hereby affirm under penalty of perjury, the <br />following declaration: <br /> <br />I certify on behalf of Johnson & VerCHff, LLC <br />contract with the Public Works Agency, City of Santa Ana, I will not employ any person <br /> <br />in any manner so as to become subject to the workers' compensation laws of California, <br /> <br />and agree that in should become subject to the workers' compensation provisions of <br /> <br />Section 3700 of the Labor Code, I shall forthwith comply with those provisions. <br /> <br />DATE: 10/21/2008 <br /> <br />By: <br /> <br /> <br />Name: <br /> <br />Title: ae-D <br />Telephone: ?!i-' 1-S-Z ~ / t:> i) <br /> <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 />4{OVED AS TO FOl\M <br />,- (z#r~~ <br />LISA E. STORCK <br />Assistant City Attorney <br />