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<br />WORKERS' COMPENSATION DECLARATION <br /> <br />I r:!aAM (ztruu' (~ hereby affirm under penalty of perjury, the <br />(Namerritle) <br />following declaration; <br /> <br />I certify on behalf of L. /... . eO II S<.d,C Ilkl 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! 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 />DATE; <br /> <br />..3-5-09 <br /> <br />By; (!aW :>ftUnAf~JffJl;f- <br />Name: ClARo/ J:.(U71 /...0 If <br />Title: PiRsJ tlfm- <br />Telephone: feOP. - t'i~ -;-E/l <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 />