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I <br />following <br />herehy affirm under penalty of <br />I certify on behnif of Studiofolia <br />(orgarilzation Name) that during the to <br />contract with the mnuuiity Devclo meni A gency City of Santa Ana, I will nt <br />any person in any <br />California, and ag <br />provisions of <br />provisions. <br />DATE: <br />WARNING: R <br />UNLAWFUL, I <br />AND CIVIL Fit <br />ADDITION TO <br />IN SECTION 3 <br />nnor so as to become subject to the workers' compensation <br />tlta� if I should become subject to the workers' compensati <br />37W of the Labor Code, I sba;l forthwith comply with tho; <br />the <br />of my <br />employ <br />uws of <br />73,2119 <br />Ely: <br />Name: _- James Dinh <br />Title: _ Principal <br />i <br />Telephone: 562-841-2512 <br />JRE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />S1-LA,LL. S UBJECT AN E1vIPLOYER TO CRIMINAL PEN TIES <br />UP TO ONE HUNDRED THOUSAND DOLLARS (,$I00,0 ). IN <br />i COST OF COMPENSATION, DAMAGES AS PROVIDEFOR <br />)FTiE LABOR CODE, INTEI;EST, AND ATTORNEY S MEES. <br />REVIEWED & APPROVED <br />'By Risk MANAgEMENT DiviSiON <br />M R 271 _- 1�-- <br />