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WORKERS' COMPENSATION DECLARATION <br />I L a j <br />1104, a&al % lL hereby affirm under penalty of perjury, the <br />(Nmnenitle) <br />following declaration: <br />I certify on behalf oi` (I�:ua64-e.Z ZZ, -,-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: Id /,Z,( /1 '5 <br />Name: L jou b <br />Title: <br />Telephone: -7t!v- 7 3' 'A"00 <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 AT'TORNEY'S FEES. <br />