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CITYoi,.5 vrAANA <br /> RISK MANAGEMENT Hu6AIW RESOUPCES ' <br /> a dw�s�on of <br /> WORKERS' COMPENSATION DECLARATION <br /> I, =3%1 <br /> hereby affirm under penalty of perjury, the <br /> (Name/rifle) <br /> following declaration: <br /> 1 certify on behalf of yrav- that during the term <br /> (Confulfofglcompanl Name) <br /> of my contract for ( o.asu -t ,N. 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 <br /> forthwith comply with the provisions and provide proof of workers' compensation <br /> coverage immediately. <br /> Date: <br /> Print Name: 1� ` <br /> `�+�Z`�►� 4v �OµErc �Is� <br /> Print Title: <br /> Signature: <br /> Telephone: �, S <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 tN: ► �.tgmlVrtturani r ArqunerrcntslWC fh't�uro(rnn L►,Y15IU1 y <br />