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•Y <br />WORKERS' ~O~'ENS.A.'fION D~CLARATIi7N <br />I ~~ ~Cr r L Ur_~`J hereby affirna under penalty of perjuxy, the <br />• (NamelJf'Itle) <br />following declaration : • <br />I certa£y an behalf of ~ ~~S that during the term of nosy <br />(O an~tlon Nanae)' <br />cozlnuct •w~ith the I r.~-~-xx~i u~. .-v; ~~.s , City of Santa Ana, l vvz11 not <br />employ any person in any matazter so as to beco~oae subject to the woxkers' cozripensati4zt <br />laws of California, az~d agree that if Z 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 ~ • ~~/ .~~d 6 <br /> <br />By: ~) <br />Name: ~ ~.--,r.7`~ 1~' L.~,s~J • <br />Title; ,--~'/~- <br />V <br />WARNING: FAILURE 'TO SECURE WORKERS' COIV,[PENS,ATIUN COVERAGE XS <br />UNLAWFUL, AND SHALL SUa:lEC'f AN EN.[PLO~ER. TO CRIIVIII~TAL PF~iALTIE" <br />AND C1V:lI.. FI1~1k,S Ul' TO ONE I~UNDRED THOUSAND DOLLARS ($X00,000). IN <br />ADDITION TO T~ COS'Z' OF COMPENSATION, D,AMA.GES AS PROVIDED FOIL <br />IN SECTION 3706 OF THE LABOR CODE, IN'~1tEST, AND A'T'I'(~RNEY'S FEES. <br />