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WORKERS, COMPENSATION DECLARATION <br />I M&gmth A hereby affirm under penalty of perjury, the <br />(NninwTlfle) <br />following declaration <br />I certify on behalf of CO N(k 1'�'AJJ that during the term of my <br />(Consultant/Conipany Now) <br />contract for 52J:LwA,&--11 services with the City of Santa Ana, I will <br />AV) A <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:-) - 6 - /I () 161 <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 />REVIEWED E3Y: 1111111RID.A 119 01) <br />RAMmWmedDMsian <br />REVIEWED & APPROVED BY. - <br />Risk Management Analyst <br />