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01-V cat 5ANt.a A.,Y,a { <br /> DISK MANAGEMENT a dlvtwil nt HUMAN 1411C )QCE5 QC.., <br /> WORKERS' COMPENSATION DECLARATION <br /> If hereby affirm under penalty of perjury, the <br /> following declaration: <br /> I certify can behalf of "v, Vic that daring the terra <br /> (Consufront/Carrmport Name) <br /> of my contract far services with the City of Santa Ana, <br /> (iypr of serviev provide) <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 /> Print Title; <br /> Signature: <br /> Telephone: <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 15 UNLAWFUL, AND <br /> SHALL SURJt~CT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED <br /> THOUSAND DOLLARS 15100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES A5 <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br /> I IH,sh htgmtlJftturrrnee Rrq„r�rte•nIs1WC!')rrluucroet 118J5d�19 <br />