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WORKERS' COMPENSATION DECLARATION <br />I 1U)s hmbi" hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration: <br />: G- <br />I certify on behalf of UJ SO rT� ''1X�'0Glll AS `that during the term of my <br />( ❑l UCompmy Name) <br />contract for C1 Ly— 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 provisio!n�ss andprovideproof of workers' compensation coverage. <br />DATE: 2 ,% !/\.._.,...�._ <br />I I <br />PvAeMIF <br />YAIA <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 />