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WORKERS' COMPENSATION DECLARATION <br />I Jose L. Romo hereby affirm under penalty ofperjury, the <br />I Name / Otle) <br />following declaration <br />I certify on behalf of <br />Jose L. Romo <br />that during the term of my <br />(ConsuitanVCompany Name) <br />contract for Event Production and Cleaning services with the City of Santa Ana, I will <br />not employ any person in any manner so as to become subject to the workers' <br />compensation laws of California, and agree that it'll should become subject to the <br />workers' compensation provisions of Section 3700 of the Labor Code. I shall forthwith <br />comply with those provisions and provide proof of workers' compensation coverage. <br />DATE: April 22, 2015 <br />By: <br />Name: J 4v. e.•, <br />Title: 6:- P�su / tet L, r <br />Telephone: (714) 812 -9227 _ <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 1S <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL, FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />a �y'. <br />Reviewe - 1�' <br />a5 <br />is iGSNP60"- <br />