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N-2018-219 <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury, the <br />(Namefl'It e) <br />following declaration <br />I certify on behalf of <br />contract for Party Supply <br />to that during the tern of my <br />(Co iam/Comp ny Name) <br />ervices 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: <br />By (I. — <br />Name: <br />�q 7— <br />Title: Lla/� <br />Telephone: 71V )A! QZ <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 />�A'. <br />