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woRicLr:s� ct�MrrNs��;rli�N nl ,1�A�1.14)N <br />11tr6 1 lUit hereby affirm tinder penalty of Perjury, the <br />64 ,10/630) _ <br />fol I awing declaration <br />T certify on behalf of _ 1111-} ( " 0 _f_ 6_(�1_GP15 that during the term of my <br />tGurupUunVt:nrn�,¢�ny Ns�a e) <br />eonfract for services with the City of Santa Ana, I will <br />not ,omploy any person in any manner so as to become subject to the workers' <br />coirpensation laws of California, and agree that if I should become subject to the <br />worh-ors' 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 />Title.12 <br />. <br />Telephone: <br />WA.tNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNTLA WFUL, AND SHALL KMIEC.T AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL .FINES LIP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SEC'I'ION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />REVIEWED '& APPROVED <br />By Risk MANht.VMENr DivisioN <br />