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A -010-0191 <br />WORR.ERS' COMPENSATION DECLARATION <br />I "WL,?5645"- t - `' 7' eby affirm under penalty of perjury, the <br />(Namelrius) ;ee-; <br />following declaration : <br />I certify on behalf of 4?4:f a27 _Gcx, that during the teen of my <br />(Orgaoushon Name) <br />contract with the , City of Santa. Ana, I will not <br />employ any person in any manner so as to become subject to the workers' compemtion <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 sha)14uthwith comply <br />with those provisions. <br />DATE: ,4 Y --I-a is <br />By: <br />Name: ?.s SEt•?- ?. ?a CTU?t l <br />Title: <br />Telephone: 9I'9? 7d.? -2'13`4 <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 PROVIDETkT& <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S l <br />APPROVE0 AS rI"O FOR'" <br />Laura Stitt Sheedy <br />Assistant City Attornee <br />W <br />wI <br />CD