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WORKERS' COMPENSATION DECLARATION <br />I fWbe)F 1131COSk hereby affirm under penalty ofPerjury, the <br />(N—dritle) <br />following declaration: <br />I certify on behalf of gck-na"�g &-Cs k, that during the term of my <br />(ComhnWompany Name) <br />contract for yl�loru,& ace 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: <br />By - <br />Name: <br />Name: t—p 4-,tr F 15�lL c <br />Title: Sok ftPeverae- ot✓Ne2 <br />Telephone: <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 />6ab`i <br />P�G� <br />