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Mar 12 09 03:37p Gina Caywood 562-436-L 025 p.1 <br />1 ,S ~~ <br />WORKCI3~. CUMNrNSn~'~t~N DE(..I_~RATtC~N <br />r <br />I ~L(l ~c,~ .hereby affinY] u~~der penalty ~~f pcrjzny, the <br />(N:un~rl'itlo) <br />following dCCI:]t"cition <br />1 certify on bel]aJf c>f ~ ~ u ~ ~ that during the term of my <br />(Urg:ui~iation Narnc) <br />cont.r:ict with the .. ~h ~ rr~c, r~trl ~~t~: ~ r ', 'ity of Stii~ta Anti .1 will not <br />employ any person. in any manner sc> as to become subject to the workers' cc>mpensltion <br />laws of Califc~rni:i, and lgree that if I should becort]e subject to the workers' <br />eotnpensation prcwisia]s of Section 37{1 cal' the [ abor Code, 1 shall forthwitl] comply <br />wit11 those provisions. <br />DATE: ~ D=! ---- <br />Hy: __ _. <br />/~ d <br />Name: _ ~-'~4!~.-._. <br />Title: <br />C k1tRl..~ <br />~'~lepliot]c: ~(~ p~ <br />WARNING: FAILCIRk?'I'O SGCURE WORKI~:RS' COMk')/IVSATIC~N C+C)VGRAGI/ 15 <br />UNLAwr'UL. AND SIIALL SUB.iFC°t' AN EMpLOYER'rc) CRiMINaL I'l/NALTlFS <br />AND CIVIL FINES l_IP't'O ONG lIl7NDRED'i'1-IC)USANI~ 1.3OLLARS ($If?0,{)()Qj. IN <br />ADDITION '1'C) THL CUS°~' Q>F CUM Y>~NSATIUN, DAMAC~F:S AS PRUV I UED FOR <br />IN ~EC"T1ON 3701 OFTHk: l.AE3OR CUI3E, INTrRi,:ST, AND A'I"Y'ORNE}"S 1-~LS. <br />e ocm . <br />~c`O~Q;g City of Santa Ana (714) 647-6987 <br />~ ~w-.,. ~ ~{ t'v ~ <br />~lv t_~ <br />i <br />r,t <br />~~wi <br />~~,-~/,I; ~~'~ C° t~'~ ~ ~ <br />' ~'~~ ~ www.sant~a//-ana,org /<~ ~~-~"; <br />