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WORKERS' COMPENSATION DECLARATION <br />I kA au; ko a r, a.. hereby affum under penalty of perjury, the <br />(N+a/rAk) O <br />following declaration: <br />I certify on behalf of kAan. Noah that during the term of my <br />(Core Name) <br />contract for R Q cc rt n.'f'i v w 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: 3z 2,9 / 9 <br />Un <br />Name: k*,orl moAsâś“4- <br />Title: j06Ln ce. S n 5 frkcor <br />Telephone: -7/ y_ 2 6 Z_ 3 Srl5' <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 />