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CITYOFSANTAANA <br />RISK MANAGEMENT &cede" 4HUMAN RESOURCES <br />Managing Risk vAwo PosNve Change <br />WORKERS' COMPENSATION DECLARATION <br />v Wnelr <br />I, / riaM 4S 1� y S �cy hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration: /l <br />I certify on behalf of V ea Lc <br />11 11jeffir%q SerVfCto&that during the term <br />'/� (Co nsb ant/Company ome) <br />of my contract for V ► 400 fiPc A S ryi c,e services with the City of Santa Ana, <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 />immediately. <br />Date: f - 7- 2 b;� % <br />Print Name:,/-A,,,,,, <br />ame: !h6M9S <br />Print Title: <br />OLon er <br />Signature: �w <br />Telephone: `914 _ 36o %� <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 ADDITION TO THE COST OF COMPENSATION, DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />I:11fisk Mgmt1insuronce RequirementsJWC Declaration 08152019 <br />K MRwganvltlimslan <br />,s REVIEWED & �APPROVM BY. <br />�AAMU9ee Imo. YKCIv1PAC <br />61B{L4¢7 Risk Management Analyst <br />