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WORKERS' COMPF.NSA'I'ION DECLARATION <br />1. C (w15 c U I.R t, hereby affirm under penalty of perjury, the <br />(NaniHri[le) <br />roll awing declaration; <br />r- ^ <br />I certify on behalf of V V4 nr,� that during the term of my <br />(cow'"✓Corny pan, Nm <br />con'ract for _mil-lu�- services with the City of Santa Ana, I will <br />not -.mploy any person in any manner so as to become subject to the workers' <br />corn pensation 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 tLose provisions and provide proof of workers' compensation coverage. <br />DATE: I <br />By: <br />Title:. o �D d `� r Ae G r <br />Telephone: <br />`�—_!C�'Jx <br />W.40ING: FAMURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />hT'I.A WFUL, AND SHALL SUBJECTAN 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 SECTION 3706 OF THE, LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />REVIEWED & APPROVED <br />By Risk MANAGEMENT DMSi0N <br />it 60621, <br />FRANCINE R. VILLAREAL <br />