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WORKERS' COMPENSATION DECLARATION <br />I ]��q✓/D h�'O yr& - hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration: <br />I certify on behalf of D14L1 /U 20YeR� P E, that during the term of my <br />(Organization Name) <br />contract with the w45Z -14. Val2:JGs 196grV4 x 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: % — 2 O — 13 <br />B ,4 C <br />Name,ia�i <br />Title: CO.t,SVGT79 <br />Telephone: 494;,/ <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 />a.PpKOV SIB AS TO FORM <br />Attor sAltOr <br />An >atant Gi[Y <br />neV <br />