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WORKERS' COMPENSATION DECLARATION <br />1 1/741!.4-L,�i'��✓CSC� Hereby affirm under penalty of perjury, the <br />(Nme/Title) <br />following declaration <br />I certify on behalf of 41c.1/1A&' �j' tt/cx5 that during the term of my <br />(Consultant/Company Name) <br />contract for /74,79,4i.</G 0/r -L services with the 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 and provide proof of workers' compensation coverage. <br />DATE: 02- - /- 20 / r <br />Name:/��i/•4C—'G q Jz S <br />Title: %f�/✓.C?�eV' C�FFICC/� <br />Telephone: 7/5/ • t?r 7. 4177 q <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 />