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WORKERS' COMPENSATION DECLARATION <br />I, Ch ereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration: <br />I certify on behalf of S rategicSnlutions that during the term of my <br />(Organization Name) <br />contract with the Facil' ties Fleet and Central Stores Division, City of Santa Ana, I will <br />not employ any person in any manner so as to become subject to the workers' <br />compensation laws of California, and agree that if I should become subject to the <br />workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith <br />comply with those provisions. <br />i <br />DATE: 4, p- 20z �.._...._...._ <br />By: <br />Name: Ch- <br />Title: Pres <br />Telephone: <br />C)5' <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSV'ION COVERAGE IS <br />UNLAWFUL, AND SHALL, SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($ 100,000). N <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />N SECTION 3 706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />