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WORKERS' COMPENSATION DECLARATION <br />I ,CUB e /�• 8� 1e' c hereby affirm under penalty ofperjuM the <br />(Names itle) �lt� <br />following declaration <br />I certify on behalf of during the term of my <br />(Organizntian Nnme� � <br />contract with the ea �¢ir¢ VO(7K (—�u4"nrr City of Santa Ana, I will not <br />0 5�c'(7r`l <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 <br />Name: /./✓ Iles .1 J'oscl <br />Title; <br />Telephone; <br />WARNING: FAILURE TO SECURE WORK KERS' 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 />N SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />