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WORKERS' CONTPENSATIOX DECL�ATIQN <br />I hereby affirm under penalty of Perjury, the <br />following declaration <br />I certify on behalf of I1060- Y, 1' 0 ova that during the terns of my <br />contract for r, (Consultant Compiny'Name) <br />services with tile City of Santa Aria, I will <br />not employ any person in any manner so as to become sit4ject to the workers' <br />Compensation laws of California, and agree that if I should become subJect to the <br />workers' compensation provisions of Section 1700 of the Labor Code, I shall fortinvith <br />C0111ply with those provisions and provide proof of workers' compensation coverage, <br />DATE: <br />By <br />Name: <br />Title: <br />Telephone: <br />WARNING: FAILURE TO SECURE WORYLERS' COMPENSATION COVERA(-iE IS <br />UNLAWFUL. AND SHALL SUBJECT" AN E'NIPLOYERTO CR11MINAL PENALTIES <br />AND CIVIL FINES UP TO ONE HU NDREDTHOUSAND DOLLARS ($ 10 0,0 00). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OFT HE LABOR CODE, INTEREST, AND ATTORNEYS FEES. <br />