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N-2p B.178 <br />WORKERS' COMPENSATION DECLARATION <br />I EA= ) )at_€ z /p gCgtereby affirm under penalty of perjury, the <br />(Namerride) <br />following declaration <br />I certify on behalf of ago—cmtrA nwA z&,ag AC6kZ )4hat during the term of my <br />(Consul tmtHComMy Name) <br />contract for M ar✓r a -(hi 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: g/?/ 11F <br />By: �% 1 , C 4 MA-Z <br />Name: 62ot€ �e/nfEZ- <br />Title: _P(LESibe(14T" <br />Telephone: 7, y 3 VS -A 7 yD <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 />\)I`. <br />Fz,Gc' <br />