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<br />WORKERS ' COMPENSATION DECLARATION <br /> <br />I vo..h EYS6j\q OWl\4 hereby affirm under penalty of perjury, the <br />(Namerr itle) I J <br />following declaration: <br /> <br />I certify on behalf of US o:J\ \A Co,",,, ,\\+, f'j that during the term of my <br />(OrganIzation Name) <br />contract with the , City of Santa Ana, I will not <br /> <br />employ any person in any manner so as to become subject to the workers' compensation <br /> <br />laws of California, and agree that if I should become subject to the workers' <br /> <br />compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply <br /> <br />with those provisions. <br /> <br />T'1..'-\OI(, <br /> <br />DATE: <br /> <br />By: <br /> <br />Cio~CL/ <br /> <br />lE-lft\-\ ~ ') ""J LV <br /> <br />Name: <br /> <br />Title: OlJ0neQ, <br />Telephone: ~ 3' (0 90, 00\ '7 <br /> <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENAL TIES <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 />