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WORI{ERS' COMPENSATION DEC ARATION <br />I MIt2-t�1 1%71i�iZdOf LPN NmuNrlan) hereby affirm under penalty ofpetjury, the <br />( <br />following declaration <br />I certify on behalf of 1,A Ur-- to (,s(k 1�l that during the term of my <br />(CmisulmnuC lnpnny Nmua) <br />contract for ' aP4.9 services with the City of Santa Ana, I will <br />ekv) cl De.1G1uP lVIG� S <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 />wonicers' 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: 7 — Z <br />I'%� 1 <br />l <br />s ')• <br />Title; _(J (n!/iM ('� l9/1 ✓'A f S e/- <br />J <br />Telephone;�p_r� <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 />nEV1E By:: CHE2EnNy �� <br />REVIEWED & APPROVED <br />By Risk MANagEmENr DivisioN <br />L_W MORMA <br />