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WORKERS' COMPENSATION DECLARATION <br />I LYrky\c) hre-6 hereby affirm under penalty of perjury, the <br />(Name/title) <br />following declaration: <br />I certify on behalf ofoU �«Z 0 V J S that during the term of my <br />(Organization Name) <br />contract with the ( c UW lcs 1�6(-- �, City of Santa Ana, 1,M11 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 />9 -I / , <br />DATE: / <{ <br />By: <br />Name: Serua�n,� V( <br />Title: aL) tte Y <br />Telephone: `2V- <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 />