Laserfiche WebLink
<br />WORKERS' COMPENSATION DECLARATION <br /> <br />I kx I ~t\C{V) J f1 O,W,v,t)W1Iiereby affirm under penalty ofpeIjury, the <br />(Name/fitle) <br />following declaration: <br /> <br />I certifY on behalf of <br />(Organization Name) <br />contract with the .5'l\\1\'o.. fWlo.. Ceo <br /> <br />that during the term of my <br />, 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 I 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 />DATE: <br /> <br />9;(../0'5 <br /> <br />By:c <br /> <br /> <br />VU-r. IlJ <br /> <br />Name: (Ull J. h ShJ 1", lJ V YY) <br />Title: l/ekvlnL.lVlClVl <br />Telephone: 0:140') '65s-_ciTYY <br /> <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENAL TIES <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 />'PI{()Vio,].J AS TO FORM <br /> <br />;"'.51 ., <br />!-, ~\.tlY (l,L <br />...;.1 SLtt shee# <br />',-:'1: City Attorney <br />