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WORKERS' COMPENSATION DECLARATION <br />I1*� L hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration <br />I certify on behalf of Alk Ja o �l G00y atdSSLo. that during the term of my <br />/ (Organization Nam <br />contract with the ��( /� �i / lir KS 4a4,y , City of Santa Ana, I will 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 />DATE: &" ,zz -// <br />By: �- <br />Name: f N /waan /was1 F <br />Title: i - t1 er <br />Telephone: ��% 0 Z- <br />- <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 />n,PID OVLL� 15 <br />�- <br />