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WORKERS' COMPENSATION DECLARATION <br />� tL 14 Hereby affirm under penalty of perjury, the <br />(Nmnerrcte> <br />following declaration: <br />I certify on behalf o�# U that during the term of my <br />(Cons company e) <br />contract ford 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 Cade, I shall forthwith <br />comply with those provisions and pro de proof o orkers' compensation coverage. <br />DATE,.f 1 <br />WARNING. FAILURE TO S <br />UNLAWFUL, AND SHALL! <br />AND CIVIL FINES UP TO O <br />ADDITION TO THE COST'i <br />IN SECTION 3706 OF THE I <br />Name:itis�97tt tYj, <br />Title: <br />Telephone: <br />COVERAGE IS <br />kL PENALTIES <br />($100,000). IN <br />