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=nNEM&,_ <br />N-2018-130 <br />WORKERS' COMPENSATION DECLARATION <br />1 5 ROM*AO hereby affirm under penalty of perjury, the <br />(N. (1-) <br />following declaration <br />I certify on behalf of ALL 5-1a2tEuwn Gu-PLS , hat during the term of my <br />(comultanV wPMy Name)) <br />contract for ibmr-, Re 6A 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 1 should become subject to the <br />workers' compensation provisions of Section 3700 of the Labor Code, 1 shall forthwith <br />comply with those provisions and provide proof of workers' compensation coverage. <br />DATE: 0-1 03 2J 18 <br />By: �A { 4i A-fL o w,7 Tz� I Ste% <br />Name: �y V� • Kq e— r\"o <br />Title: ?tc.L&it;t- <br />Telephone: 545. 2-'14 . T 3 41 <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 />Scanned with CarnScanner <br />