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l4'OI21:Ek5` C0~9YLVS~A~f[OK DLCL,yR:yTlO~' <br /> 113~,j~,v tvj~Tl.E_`j Itrreby affirm under penalty afperjury, the <br /> ~ , . <br /> litlla~~ iu;~ dcrlaratiun <br /> QR2A+~+ w NI Ct,E-Y D (SA <br /> I certify on beha]fof $~r~tiSC Sa~uT~.,S that during the term of mp <br /> n,...,. , <br /> <br /> eunu:na With the S.~Ir~~9 ANA PxIcE 6lEPT, . City of Santa Ana. I n'ill no[ <br /> employ any Peron in any manner sa as to become subject to the warkcrs' catnltcusalion <br /> laws of Califontia, and agree that if I should becontc subject to the ~~~itrkcrs' <br /> <br /> cumpens;uian provisions of Section 37011 ofthe Labor Code, I shall fonhwlth campiy <br /> kith [itac prae°isions <br /> I)nrL: !l-l4-0~ <br /> riy: <br /> \amc: ~2~1~ 4~ HI i <br /> c-E 4 <br /> Title: SOLE, P¢oPRLETn2 <br /> felepltane: CjlY, Sly-ooh 1 <br /> 11'AKVIVG: fAILLRL TO S[C'CRE ~L'ORKF.RS' C'O\1PENS.A'rION ('OVER:~GE IS <br /> LTLAGf~PUL.:1~1D SHALL Sl!B.JECT AN E~IPLOY6R'LO CRINIIVAL PEN.~ILTIES <br /> AiyL) C'IVIr. F[VGS (JP TO ONF. HGn'I)REI) I'iIOUSAVD DOLL'IRS (5100,000)- IN <br /> :~DDITIOV TO THE C'OS'f Clf COl•9P[NSATIUV, DAMAOFS AS PROVII)F:D F'OR <br /> IV SECTI(-)V 3706 OF MIL L,16UR ('ODE, INTERF.ST_.ANf) A'fCORK~I"S FGES_ <br /> i FORM <br /> ~ - . <br /> -U~ <br /> ..qty iAtior.ey <br /> <br />