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FP(fM :Bay Bred Prlving BoMOI FfgNE W.: 510 E�8 4408 ]oo. 05 2907 96:S2RI P2 <br />IPoOk <br />Vl <br />I EBINq 6Vdq SNftRa6 @lherobyffmrmtponalryof*aIytl% <br />Nbeft) <br />following declaratlon <br />Sfl�'V pPIpE�'t EO�IEc <br />fcertityonbchnlfof�'1 �d PIV1Ny flNau� �tduong�ecemsofniy <br />nmt) <br />ronpaGwithJta, bINEOaNER' �l_,Cityof�AuNlwJltat <br />dnplayanypasoninanymaonee6oasmberomesu6jeattothawo rkera'romp�sadoa <br />Lnvs of California, and agree flint tl l sMuld biome mbjeG to tlu wotvers' <br />compensation provisions of Sr* 9100 of tklabas Code, I shall fmthwifb romply <br />wdsh�auprovisioas. <br />I ( a - <br />By: _ <br />Name; �Itlfl VIEVRp ' _ <br />Title; OWVIdbSNllkalTdm _ <br />Talephoae: till • 531.7751 <br />wA�a, Fnau� �o s�CURS woRr�s' aD�ENSa7?oN rov�,aDl! Is <br />UNLAWFOI, ANDSHAI SSUBIFC1 'ANEMPLOYERTOCRIM[NALPENALT�B <br />ANDCIVI4F➢ JESUPTOONBHf1 NDREDINOUSANDDOLLARS(9100,Otl0), �' <br />ADDff fONTOTHEC09TOFCOMPENSA11oN ,DM4108SASPROVmF�FO'R <br />"ti SEC' fI 0N37060FTHRIABORCADE ,MTEREST,ANDAITORNR'1'SFEES. <br />APPROVED AS TO FORM <br />IdurB 81,n S,fCJ/ <br />Assistam City Alierey <br />