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WORKERS' COMPENSATION DECLARATION <br />I G`~°~ ~ ~~~^~ ~`''~''`~ hereby affirm under penalty of perjury, the <br />(NameJTitle) <br />following declaration <br />I certify on behalf of ~~~~i ~~ %~ ~'rNu~ oNUL that during the term of my <br />rganization N e / ~ <br />contract with the ~X°L ~i~~ o /~iJ~;~~.-e ~ ~wf '~, Ci y of Santa Ana, I will not <br />employ any person in any manner so as to become subject to the workers' compensation <br />laws of California, and agree that if I 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: ~~ ~ ~ % ~ V-~ c' ~ /ti TC-~L Nl~Tir~N~C <br />~I <br />B <br />y• <br />Name: /' o r~ ~. ~ ~=+~ ' e V' V <br />Title: ~ S i 1(,~~-N~ <br />Telephone: ~L ~ ~ ~7~ ~ ~ 35~~~ <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <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 />