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I jY hereby affirm, under penalty of perjury, the <br />(N t10 <br />following declaration: <br />I oa fy on b4ali; of rv-- JZZ4.s Oat durWg the term of My <br />( aaizuUonNwaae)' <br />coz�i�actwlththo �nia ,wviros, City of Santa Ana, I will not <br />employ any person in "y manner so as to become subject to the workers' compensation <br />laws of California, and. agree ghat if I should become subject to the workers' <br />compensation provisions of Section 3760 of the Labor Code, I shall forthwith comply <br />with those provisions, <br />DATE;/ <br />Jay; <br />Name: Z 1 fin, A` L,40�) <br />Titles <br />Telephone.- s� 1 � �y� % 4;1 1S'21 <br />WARNING! FAILURE TO SECURE WORT R$' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL STJWECT AN EMWLOYER TO CRIMINAL PENALTIES <br />AND CIVIL FINES UP TO ONE RUNDREEU THOUSAND DOLLARS (Sl'00,000). IN <br />ADDITION TO TIDE COST OF COMPENSATION; DAMAGES AS PR,OVIDE) FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. . <br />