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WORKERS' COMPENSATION DECLARATION <br />I <(/5 e ./ • (x s _ MLhereby affirm under penalty of perjury, the <br />(Nam rtIe) <br />following declaration <br />I certify on behalf o£ e s c ts[46that during the term of my <br />(Organization Nano) <br />contract with the Sep o <br />c' fir¢ (uu�?K Crei ?.,r City of Santa Ana, I will not <br />bfh <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 />---��, <br />DATE: �'�2 ( -= �rs•'�' G: /d�-�d � <br />BY: 1G1& N1 >s4,� 1444, 1M <br />Name: l.P/r;� ��� ,�! �'oscl <br />Title: P/ar- <br />Telephone: __`%/1e • r,9__ <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMNAL 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 />