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WURKLPS' C0b1PENSATION DECLARATION <br />1 _Y hereby affirm under penalty of petjury, the <br />;>w i tfo <br />tollowin6 declaration: <br />I certify on behalf of_--5A- s� o _ 3 that during the term of my <br />�fonmlumr ComN;ut �V'unicl �-� <br />C0I1Iract tot' F'@CC68tI0n CHSS25 service's With till' lty 01'Santa Ana. I will <br />notellpioF tin♦'person ❑1 any manner so as to become subject to the 4V"orkers' <br />compensation laws of California, and agrek that if'[ should become subject to the <br />evorkers` compensation provisions of Section 0700 of the Labor Code, I shall forthwith <br />comPly with those provisions and provide proof of %vorkers' compensation coverage. <br />DATE: '?,I-ZIIel <br />By: <br />Name: VDNM PA S <br />Title: ownw <br />Telephone: I4 <br />WARNING: FAILURE TO SECURE WORIfERS' COVITENSATION COVERAGE IS <br />UNLAWFUL. AND SHALL SUBJECT AN EMPLOYER TO CRni,ITNAL PENALTIES <br />AND CIVIL FINES UP TO ONE HUNDRED THOUSAND' DOLLARS (StO0,000), IN <br />ADDITION TO THE COST OF CO iPENSATT ON, DAtV[AGES AS PROVIDED FOR <br />IN SECTION 3706 OF TILE LABOR CODE, INTEREST. AND AYFORNIEY`S FEES. <br />e\]a <br />