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WORKERS' COMPENSATION DECLARATION <br />I [7� I Ct 4 eq Rn e h', V) hereby affirm under penalty of perjury, the <br />(Namefritle) <br />following declaration: <br />I certify on behalf of i LA1-1- Sc fim}hat during the term of my <br />/ (Organizali n Name) <br />contract with the ce- City of Santa Ana, I will not <br />employ any person in any manner so as to become subject to the workers' compensation <br />laws of California, and agree that if I should become subject to the workers' <br />compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply <br />with those provisions. <br />DATE: G3 I i 121 <br />By: _ 2_ <br />Name: {'tat 12ocn <br />Title: rY' i to GI ) a <br />Telephone: C5LLJ jq6 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />