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~v-aoo~-o~:~ <br /> WORKERS' COMPENSATION DECLARATION <br /> I T~i1~111 N(1 N~ <br /> OGII~EILhereby affirm under penalty of perjury, the <br /> (Name/Tifle) <br /> following declaration <br /> I certify on behalf of 1l~nl rJm PDoc, ~ SSA' that during the term of my <br /> Organizatim Name) <br /> contract with the ~DJ'ijm, D~/~ ~TlG~ FDQT~'City 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 /> <br /> DATE: r 1 - ! t7 ~ yR <br /> sy: <br /> Name: ~ o w <br /> Title: Wit, ,~Frrr+~ P~_ <br /> Telephone: fi J y o - ~'),,o <br /> WAB.NING: FAII,URE 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 /> <br />