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I KR WiV-S hereby affirm under penalty ofpedury, the <br />(Namwrilk) <br />following declaration : <br />I certify on behalf of O imb-:' that during the term of my <br />(cowulmnt/c mpany NMO) <br />contract for0li2 C(}y VW&t services with dte 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: <br />By; <br />Name; i tiUO-S <br />Title: OUJ V1 _ <br />Telephone; Jb-6 s(9— <br />Reviewed by <br />Carmen Acosta <br />PRCSA/Recreatiorl <br />