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z1 <br />WORKERS' COMPENSATION DECLARATION <br />I ��. �j hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration: <br />I certify on behalf of /' ar -femyi L,-,oy ao &o.that during the term of my <br />(Organization Nam <br />contract with the A i C 1AJO.- rl—'S oy,c , 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: & -1 ! -/ <br />By: <br />Name: <br />Title: 0,,,n er <br />Telephone: 9y � 2 U z- <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 PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />