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I hereby affirm under. penalty of pedury, the <br />following declaration <br />I certify on behalf of Pbt <br />that during the torm of my <br />contract for <br />services with dw City of Santa Ana, I will not <br />employ any person In any manner so as to become sulrioct to the workers' compensation <br />laws of California, and agree that if I should become subject to the wk)rkm.' <br />compensation provisions of Section 3700 of tile Ubor Coda, I shall forthwith Comply <br />with thos provisions and provide coverage. <br />DATB� 21 k- <br />By: <br />Nalne, <br />Tifle: <br />Telephono: <br />I <br />WARNING: FAIL(.METO SEXURE WORK-1,-,RSCOMPJ.',.'NSAI10N COVERAGE IS <br />UNLAWFUL, KND SHALL SUBJEX,'TAN IWPLOYE R -1-0 CRIMINAL PENAUI'11"' 'IS <br />AND CIVIL FINES UP TO ONE HUNDRI.,,l)THOUSAND DOLLARS ($1 ()0,000), IN <br />ADDI'I'lON'R)THE COST 0FC0MPF'NW'I(.Y.N, DAMAGES AS PROVIDFI) FOR <br />IN SECTION 3706 WITIE'LABOR CODE, INTEREST, AND Ar'J.'ORN.F,Y'S FEES. <br />