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Exhibit A <br />WAIVER <br />WORKERS' COMPENSATION DECLARATION <br />G,,\aP rvto ?-j T A 6? <br />I ?C?C 3T1V? D I whereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration : <br />I certify on behalf of ]a±C U a A IN f A<XlEt " that during the term of my <br />(Organization Name) <br />agreement between the 'j}} 6" (Zti1 j r? kofLfk'C? and the City of Santa Ana, for <br />QLA'Zfr SA-oJT?F Nl* <br />M U R N L purposes/services, I currently do not not employ any person in any <br />manner so as to become subject to the workers' compensation laws of California. I agree that if <br />this changes and I should become subject to the workers' compensation provisions of Section <br />3700 of the Labor Code, I shall forthwith comply with those provisions. <br />DATE: <br />Signature <br />I <br />By: 1 - <br />Name: <br />Title: <br />(?C Zy? j\ ?EZC?` <br />Telephoner ll! ?j 2 , °23°J'2 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND <br />CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION <br />TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 <br />OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />10