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CITYOFSANTAANA�K <br />ky <br />Managing Risk vomo POSMM Change <br />S muSti <br />Aw Aa6l- 30 ) A -AT .r 7' hereby affirm under penalty of perjury, the <br />(NamelTiltle) <br />following declaration: <br />I certify on behalf of L A )V& D1 <br />(GansultantlCompany Name) <br />that during the term <br />of my contract for 6 R vt N r (Z e ci p iy\/*r services with the City of Santa Aria, <br />(Type of service provided) <br />I will 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 the provisions and provide proof of workers' compensation coverage, <br />Date: 5E't' 1` -12 .2 c> t <br />Print Name: fl-N Cr i 1A n16 0 <br />Print Title A P T1 S T <br />Signature: <br />Telephone: C-7/4 6 .- 4- — 4 F Sly <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND <br />SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED <br />THOUSAND DOLLARS ($100,000). IN ADDITIONAL TO THE COST OF COMPENSATION, DAMAGES <br />AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, <br />1. RiskMgmtVnsuronceRequirementslWCDeclaration 08152019 <br />