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<br />Apr 23 07 09:45e FutureTouch Technology <br />15623Gfi8887 p.t <br />WORKERS' COMPENSATION DECLARATION <br />z (~6H`t <br />1 _~l ~~1 i~ w1 ' hereby atfirro under penalty of perjury. the <br />a„uTk T~ <br />following declazation : /n /~ y <br />I certify on behalf of ~~ 7~+f t' I ~e{f ~~~(~lthat~dining tip term of my <br />(o~ iz ' it~me) <br />contract with the C )~ ~ ~rn~ JQ~q ,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 Califamia, and agree that if I should become subject to the workers' <br />compensation provisions of Sectioa 3700 ofthe Labor Code,1 shall forthwith comply <br />with those provisions. <br />DATE: ~ T ~ _ <br />o ~°~ <br />ao~9 ~~ <br />G'~ <br />R <br />GASP ~ G yOP~~rey <br />~Ststaot <br />By: <br />Nam <br />Title <br />Telephone: ~~~~ ~fo' ~ /X3~ <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COV ERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIV 1L FINES UP TO ONE HUNDRED THOUSAND DOLLARS (S] 00,000). 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 />