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WORK C0%1.RFN,,SATI0N DECLARATION <br />I , ,�,z ._ hereby ailiriD under penalty ol'perjrtry, tlic <br />{1r`iuneTitiri <br />fbilowing declaration <br />I certify on behalf of Ur; rrr" 1�11that during the term of my <br />1[ v1mRll n0CumNny NAmc) <br />contract iiAr J` ... P services with the City of Saula Anis, I will <br />not employ airy person Ili any matiner so as to become strlLjcct to the workus° <br />compensation laws ol'California, and agree that if should become subject to tate <br />workers" compensation provisions of Section 3700 of the Labor Code, I shall forlhwith <br />comply with those provisions and provide proof of workers' compensation coverage. <br />DATE: 4`7 r .s <br />t?✓t Gad k <br />Illy: <br />Name: Ja 1 i J <br />.Title: C E U %�t11 s r,p <br />Telephone: _! -37r �q C <br />WARNTNG: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />ANT) CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (S I00,000), IN - <br />ADDITION TO T E C OST OF COMPENSATION, I)AIv1AG S AS PROVIDED FOR <br />IN SECTION 3706 OF TIME LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />Revke\Ned ay`. <br />WLPI <br />p�tG <br />