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NVORKERS'COMPENSATION DECLARATION <br />I Servando Varela / Owner hereby affirt-VI UlIdCr Penalty 0I'perjury, the <br />followingetc I <br />Aarati(. ri <br />I certify on behalf of --111 XV SOlUtiOTILS __ ll)Ztt ClUring-itIc tertermot'n-ty <br />con -tract with the Worhs tkagncN . ......... __ Cityof-SantaAna, I will not crylploy <br />any person in, ariy manner s0,1'S to bCC01V1esL1bjLct to the %vorkeis' con-tpensation lags of <br />Calitbrnia, and agree thae itA should become subject to the workers' compensation <br />provisions ot'Sectitm 3700 ofthe Labor Cc)dc. I shall t6rtliwith comply with those <br />Provisions_ <br />DATE:MaN, 13, 2010 <br />Bv: Owner <br />Natne: Servando Varela <br />Title: Owner <br />Teleplit)[1c: 71 i Zfig-819t} T_ <br />WARNING: FAI IAAR F TO SECURE WORKERS' COMPENSATION COVERAOF IS <br />UNLAWFUL- AND SHAI.I. SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL FINES (.7PTO ONE HUNDRED 7"I- DOLLARS ($100,000). IN <br />ADDITION TO -1-HE COST OF COMPENSA'fTON, DAMAGES AS PROVIDED F(JI2 <br />IN SECTION 3706 OF TI IF LABOR ( INTEkS_F. AND ATTORNEYS FEE -S- <br />