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N-2019-033 <br />WORKERS' COMPENSATION DECLARATION <br />I 1IS a� } hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration: <br />I certify on behalf of UhSO RDJOCC AS I N during the term of my <br />( all it/CompayName) <br />contract for 1r Cvq 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:- <br />B <br />Name: ✓/�5l✓1 V�v P�ae1f <br />[/)� <br />_ J nJG. <br />Title: L ��/% A.0 sothe ' <br />S <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 />1?01N)��i <br />���as <br />