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hereby affirm undor penalty of perjury, the <br />iollowing de4flaration, <br />I md fy on behalf of flz04,� QVM% that during the term of my <br />(cumultanucompoy Hamm) <br />contract'for a ....... services with the City of Santa Am, I will not <br />employ any person in tiny manner so as to become subject to the workers' componsation <br />laws of California, and agroo that if I should become subject to the workers' <br />compensation provisions of Section 3700 of the Labor Code, I shall forthwith oomply <br />with thou rovisions and provide prour covurago. <br />D 1-9 <br />BY: <br />... .. .....mom..._......,_.._ .Narne: Aga <br />Title: <br />WARNINCI: FAILURE,TO SECURE WORKERS" COMPENSAI'M COVERAGE IS <br />UNLAWFUL, AND SFIALL SUBJECTAN EMPLOYER TO CRIMINALPFNA.131EI�s <br />AND CIVIL PINES UPTO ONE HUNDRIU)TIMUSAND DOLl.,ARS ($1,00,000). IN <br />ADDMON 1WfflF COST Cris COMPENSMION, T.)AMAGES AS PROVIDED FOR <br />IN SEXTHON 3706 OFTHE, LABOR CODE, INTERI-NT, AND ATTURN.FY'S FEES. <br />