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WORKERS' 90MPENSATION DECLARATION <br />I L w-- hereby affirm under penalty of penury, the <br />(N ane} <br />following declaration: <br />I certify on behalf of / M1 C%%S that during the term of my <br />( aaizgJon Nam)' <br />contract with the City of Santa Ana, I will not <br />employ any person in my manner so as to become subject to the workers' eompensatioo <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 />-Fe- l09'c/� <br />B.y: ) <br />Title: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATIOI\'1 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 />