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jk;� (�v/,EGLfe- ljegl, cit' sig%s ",-00 <br />WORKERS'CO"MMP-E�N`S-A�TIIO,N DECLARATION <br />I �. 1 `hereby affirm under penalty of perjury, the <br />(Nwne iltle) <br />following declaration. <br />I certify on behalf of�?^�zat during the term of my <br />41111A VVC=VMy Name) <br />contract for,-400kktY tY a•_f+ 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 if I 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: C1 -x 4 <br />By: <br />Name:yoA�o;,t� .LZ. <br />Title: G�4f— 0,0a�� <br />Telephone:� <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <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 />