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WORKERS'COMPEPNSATION DEcLARA,rION <br />I Derek FrqtheimJP—residtq—t hereby affirm under penalty of perjury, the <br />(Naaw,Tidc) <br />following declaration <br />I certify on behalf of Acire, Incorporated that during the term of my <br />(Orpnization N=c) <br />contract with the Department of Public Wq- City of Santa Ana, will not employ <br />any person in any manner so as to become subject to the workers' compensation laws of <br />California, and agree that if I should become subject to the workers' compensation <br />provisions of Section 3700 of the Labor Code, I shall forthwith comply with those <br />provisions. <br />DATE; <br />Title: President <br />Telephone: 9499275-6365 <br />WARNING., FAILURE TO SECURE WORKERS'COMPENSATION7 COVE -RAGE IS <br />UNLAWFUL, AND SHALL SUBJECTAN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN <br />ADDITION TOTHE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY' S FEES. <br />APPRcwt-j--) AS' J'() J,-(,)RM <br />Assistant citY AUOrney <br />