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WORKERS' COMPENSATION DECLARATION <br />I `Us A fxs c ggiereby affirm tinder penalty of perjury, the <br />(Nam itlz) 1 0(FF <br />following declaration <br />I certify on behalf of ,/ 5, , c � de ✓ �ltithat during the term of my <br />(Orgamznlion Nam) <br />contract with the e.a tq i¢n¢ 6�1o(7Ku �nr� City of Santa Ana, I will not <br />o �cDfl <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 4�'4L <br />Name: /fir ;4 e�y "f/_ gosG4� <br />Title; 66 4I of s e Zo e- <br />Telephone: '7 1!l1 , -5-6S = 16 (1,9 <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 />N SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />