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i <br />WORKERS' COMPENSATION DECLARATION <br />I S�O/1/ f�iUl�/ %, �/V/1/E%Lhereby affirm under penalty of perjury, the <br />(Name/Title) � <br />following declazation : <br />I certify on behalf of r7LF/T /n/c�m %,Doc. Q SPi9' that during the term of my <br />Organization Name) <br />contract with the ��irr1. �El/, �6-T�Gy �D2 %�� 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 />DATE: 11 - It7 - v`t <br />By: <br />Name: /� J o {.w <br />Title: [ J1,tJ,.JFr !.•ml�.,..a�.., P� <br />Telephone: i"► 1 tl °i o Ea - � 2,01 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CNIL 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 />