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N-2019-008 <br />WORKERS' COMPENSATION DECLARATION <br />I I laVllS��ti ��1� �'jJt� ",--hereby affirm under penalty of perjury, the <br />following declaration: <br />I certify on behalf of JtGf 6 N Iola Yl (0 _ -- <br />that during the tern of my <br />/ (Cnitstrh mPC �tiiigm Name) — <br />contract for Zu'l t ,' (caq„1 � b ' E':draices 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: 2� 20I t <br />B� <br />A� ,i� r, <br />Name: 000,4 )III�;lri1 ` <br />Title:.tc <br />Telephone: <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 />