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WORKERS' COMPENSATION DECLARATION <br />I J) ��111C) <br />�r���I �—. hereby affirm under penalty of perjury, the <br />(NiINCP <br />following declaration: <br />I certify on behalf of 7- vc1Y�Sr,Y1 h 5�)r tnfF that during the term oI'my <br />(Q BSU114nllCompanv Nnnu) <br />contract 1.or y �� � L1S, 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: 1,2 J,/ IM <br />Name: <br />Title: <br />Telephone: <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 />