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WORKERS' OMPENSATION DECLARATION <br />I ~t,-,r ~~~_ hereby affirm under penalty ofperjury, the <br />(Namo/X'itle) <br />following declaration <br />I certify on behalf of ~ ~S that during the term of m3' <br />o~aa~tion xmne) <br />contract with the I n~-,~,~x~i u~ t ~fe~-v~ rot ~ Gity of Santa Ana, I will not <br />employ any person in any irianner so as to become subject to the workers' compensation <br />laws of California, and agree that if I should become subject to the workers' <br />compensation provisions of Section 3700 of the Labor Code, I Shall forthwith comply <br />with those provisions. <br />DATE: ~/3~d 6 <br /> <br /> <br />Name: L,.r~G., ¢' L..en.c~ <br />Title: ,~-~~- _ <br />v <br />Telephone: `~/d ~Id~`%a~~/ <br />WARNING: FAILURE'I'O SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, ANA SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($1'00,000). IN <br />ADDITION TO TIIE COST OF' COMPENSATION, DAMAGES AS PROVIDED FOR <br />AV SECTION 370b OF THE LABOR CODE, INTEREST, AND ATTORNEY'S F);ES. <br />