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WORKERS' COMPENSATION DECLARATION <br />I (? a ktJ Lfl (LpCk I'?'DES 10?•('r hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration <br />I certify on behalf of ?C SR?E"(?J ?t?pG . that during the term of my <br />(Organization Name) <br />contract with the 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: ? ? ? ?»? <br />Y? <br />Name: ? ltl? ? -?L-?C?" <br />c <br />Title: ?1?5??%tJ"? <br />Telephone: ???- G?- ?? ?, <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.