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x <br />WORKERS' COM'ENS.ATTON DECLARATION <br />I /cr Lg, ,' hereb at'firm Uader penalty of <br />? Y perjury, the <br />(Name Title) <br />following declaration : <br />I certify on behalf of 77?; k.S that during the term of .ray <br />(°,?aai?etlon I1am?e) <br />contract with the /?1 u? rQ.s , City of Santa Ana, I will not <br />employ any person in any nU=er 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; • x-7/3/6 6 <br /> <br />By: <br />Title: -?- - <br />Telephone:? <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 ($1'00,000). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND AT'TORNEY'S FEES. .