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WOR.KER.S'(,'QMPE'NSA`FlQN DECLARATION <br />FV&I/ hereby affimi under penalty of perjury, the <br />(NameiTid(,,) <br />following declaration <br />— <br />I certify on behalf of that during the term of my <br />- xl-�—Eu <br />(comotanucompany Name) <br />contract for —<--5 services with the City of Santa Ana, I will <br />not employ any person in any manner so as to become suject to the workers' <br />corqpensadon laws of Califomia,and agree that ifl should become subject to the <br />workers' compensation, provisions of Section 3700 of the Labor Cor de, I shall florthwith <br />co� ljply with those provisions and provide proof of workers' compensation coverage. <br />DATE: 7 <br />By: <br />Nwne: <br />7S- <br />Tho elep ne: -C <br />. <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND STIALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL FINES UP TO ()NE HUNDRED THOUSAND DOLLARS ($100,000). IN <br />2 .DDITION TO THF COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />