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<br />, . <br /> <br />WORKERS ' COMPENSATION DECLARATION <br /> <br />I ~~H iA""2>. ti+ I ~ hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration: <br /> <br />I certify on behalf of <br />contract with the #0 US-Ù\1 <br /> <br /> <br />'HiA:2). VA lIe, that during the term of my <br />rganization Name) <br />PRo- ð '1.e.A- ~ , City of Santa Ana, I will not <br /> <br />employ any person in any manner so as to become subject to the workers' compensation <br /> <br />laws of California, and agree that if! should become subject to the workers' <br /> <br />compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply <br /> <br />with those provisions. <br /> <br /> <br />DATE: 08- 3/- 0 ,¡ <br /> <br />By: t!t.jN7 H-;¡t¡.:J:::>. V,q I k:.s <br />Name: CytJ7'Hi.4 ~. tI~I/~ <br />Title: ¿)tJ.),7e¿ <br />Telephone { 7¿'~ 7S-/-(O 81 <br /> <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 /> <br />ß~*7 <br />