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WORKERS' COMPENSATION DECLARATION <br />�r)& -, hereby affirm under penalty of perjury, the <br />following declaration <br />I certify on behalf ofd p/Fm, r,( (4 ` ` I () ( i ^rhat dtlring the term of my <br />contract for �jL �CansultawCOMp y Name) <br />1M Obl/services with the City of Santa Ana. I will <br />Y'. an9» 1 nG- n&Y-t� - f <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: <br />--_ By: <br />Name: wer 1 5� <br />Title: L ttP (L <br />Telephone:_ -7/ <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 />