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WORKERS' COMPENSATION DECLARATION <br />I IeIC144% e4AIde56S hereby affirm under penalty of perjury, the <br />(Namefrille) <br />following declaration <br />I certify on behalf of that during the term of my <br />(CenauhanbCump:my Name) <br />contract for fs18l t!:�6/c6ci 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: S'36 -o�"Ja <br />M <br />Name: �/�r 4454-- e•9itA� <br />Title: lwl cpe-,G/L'eyl <br />Telephone: ;?/y. o?g). el?9f90 <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 />ZIP <br />Wk «�' %%A <br />