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N-201&220 <br />WORKERS COMPENSATION L)ECLARATION. <br />I d/- hereby affirm tinder penalty of perjury, the <br />(Nemclfllte) <br />following declaration: <br />I certify on behalf of r P ,, r that during the term of my <br />(COn8UI1W1V ompnny Nmne) <br />contract forX 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: / %/Y <br />M <br />Nam <br />Title <br />Telephone; 9VA- 1? 0 3- 56 11 <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 ($100,000). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'$ FEES. <br />