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WORKERS' COMPENSATION DECLARATION <br />I T4.e iguuag'f G"hereby affirm under penalty of perjury, the <br />(Nmndritle) <br />following declaration <br />I certify on behalf of �� �fiafring the term of my 3u <br />i nUCompaM Ne ) ^ (Cauulle <br />contract for 4:�°� ` rr�i'r °' T 1lrservices 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: v a� <br />By - <br />Name: <br />Title: f >r+t Gi Q. <br />Telephone: .I N • `1-1 N ' <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SMALL 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 />