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N-2018-155 <br />WORKERS' CO PENSATION DECLARATION <br />Z/r'r t hereby affirm under penalty of perjury, the <br />(Nan&Fitle) <br />following declaration: <br />I certify on behalf of U(LE (;l?k4� /� that during the germ of my <br />g�7 Cooax ltan Company Name) <br />contract for / ( 6-57Mi(n)-S . _ 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: f !_ 1 5 <br />By: e` <br />Ad +sue <br />Title: _ <br />Telephone: 909 <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 ($I00,000). 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 />