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WORKERS' CQMPENSATIOI`�l DECL& TION <br />M_ <br />1; hereby affirm under penalty of perjury, the <br />following declaration: <br />I certify on behalf of _P 3,F6 M ST-)? ojt,� 6, that dwing the term of my <br />(CmisultantlCompany Name) <br />contract for services with the City of Santa Ana, I will <br />not employ any person in any manner so as to become subj ect 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: 'IS- 201 <br />By: <br />Name; <br />Title:?F5 (Z- <br />Telephone: 1/9 - 8 Is--s - V/S- <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVER A-G- E IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL FINES UP TO ONE, HUNDREI)THOUSAND DOLLARS ($100,00%, 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 />RUE'VEWEI)BY': EUNICE HERIIENA (F"G rJ <br />