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t 0 V r e d w 'Itci'c S<ttS 't f`Gau<-�i. <br />WORKERS' COMPENSATION DEsCLARATION <br />I � � `hereby affirm under penalty of perjury, the <br />{Name/Tiile) <br />following declaration <br />I certify on behalf ofDu at during the term of my <br />{Gansu WnttContRwly Nan.) , <br />contract for _ kyr services with the City of Santa Ana, I will <br />not employ any person in any manner so as to become subj cot 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: aa�SrG' 4 l <br />Name: 1�w lk �ItZmm <br />Title: hX tl * ^ Svc <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 (5100,000), IN <br />ADDTT"ION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3704 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />