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WORKERS' COMPENSATION DECLARATION <br />I ��Q/y1QS P hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration <br />Web Sir✓tC�S <br />I certify on behalf of irrigINPP! tltq that during the term of my <br />�.�CQ� (Con to t/c-mpmly ame) <br />contract for �G�B' (� j IG 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' compensaytiioon coverage. <br />DATE: %� �� ® v2+� F, A / <br />By: Y7 r� y Y <br />Name: t%I J Cilci l /1 ref <br />Title: QGUne - <br />p -1 <br />Telephone: m1�����/��� <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 />Reviewed by: <br />�- Silvia Cuevas <br />PRCSA/Admin. <br />eeS <br />