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A'01t]E,ER,aLLQM JILI�IIQN 1NS.LECLARATION <br />— -_ <br />I Dorek!iLelhoirnLrLqi4iLnLherc,,by affirin under penalty of perjury, the <br />�NgmoTilk) <br />following declaration: <br />I certify on behalf of Acire, Incorporated that (luring the term of my <br />Conti -act with the- Denartnient of Publig�Wor�-g, City of Santa Ana, I will not, employ <br />any person in any manner so as to become subject to the workers' compensation haws of <br />California, and agree that if I should become subject to the workers' cornlyonsation <br />provisions of Section 3700 of the Labor Code, I shall forthwith comply Nvith those <br />provisions. <br />DATE: <br />Title: ---Prcsident <br />Telephone: - 949-275-6365 <br />WARNING: FAILURE Tib SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SU13JECT AN EMPLOYER TO CRLMINAL PENALTIES <br />AND CIVIL FINES UP TO ONE 1IUNDRFD THOUSAND DOLLARS (SI00,00). IN <br />ADDITION TOTEM COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. <br />APPROVED AS �()WhA <br />