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\N01W.RS" CONII'FNSA`ION DF(A.ARATION <br />_GW +fat rcbv affirm nncier Penalty of perjury, the <br />(Naoie; r,ii:a - - <br />f)llvwing declaration ; <br />1 certiN on behalf'of i w.J� -T-N4^' that (luring the taut army <br />tC'onsudt;nUOnns uy Now) <br />comi-nct for `ems to fV A services with the Chy of Santa Arta, I will <br />not employ any person in any )Wanner so as to become subject to the workers' <br />compensation lakes of California, and agree that if I should became subject to the <br />workers° compensation prtavisions of Scclion 3700 of the Labor Code, I shall firrthwith <br />comply with those provisions and provide proof of workers" compensation coverage. <br />Name: ok k4V CS Ad'1r'✓ <br />Lille: <br />I'elepltorac: 1 '7G C <br />NARNINU I AILURE 10 SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL FINES UP TO ON'E HUNDRED THOUSAND DOLLARS {SIft0,00Q'}, IN <br />ADDITION '1't:? "I'I li: C OSTOF C OMPENSAT ION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 01--fill" LABOR CODE, INTEREST, AND A rt`OR'NFY S FF.ES. <br />