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15.08.2019 15:22 <br />17145999996 #0217 P 5/19 <br />WORKERS' COMPENSATION_ DECLARATION <br />(4V16Qxrcby affirm under penalty of perjury, the <br />(Nwnerntle) <br />following declaration <br />T ec ' If of 1 that during the term of my <br />(C01130ent/Company Nan <br />contract for 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 I forthwith <br />comply with�thoos provisions and prod prao workers' compensation coverage. <br />DATE: ii <br />Name: <br />Title: <br />Telephone: 1 �{ ��''� l qL4�/ GI <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 />