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<br />WORKERS ' COMPENSATION DECLARATION <br /> <br />,::;;.;eue. l?1';(k!jk~rebY affirm under penalty of perjury, tbe <br />(NJlmcrfltlc) <br />following declaration: <br /> <br />, certify on behalf ofl?.::rI~~r!.u(1j'lt:/.---'-.e / that during the te~f my <br />r"7) ~ (0 niuuon N.mc~~s 7!' M"(''''''~ .t:5-.:s.-/.5 <br />contract with the 1Zld.s ~ /pa;~o"J /)fI' , Cifyof Sauta Ana. I will not <br /> <br />employ any person in any manner so as to become su~iect to tbe workers' compensation <br /> <br />laws of California, and agree that if (should become subject to the workers' <br /> <br />compensation provisions of Section 3700 of the Labor Code, I shall fO.rthwith comply <br /> <br />with those provisions. <br /> <br />DATE:..;;;j~ 1~~f20..K <br /> <br /> <br />"/d~,,';- <br />.'- <br /> <br />,\,~;-' Telephone: (959 ~L).~- s..~h:::L... <br />"rr <br />,-.' / <br />U <br /> <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRJMINAL 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 />