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WORKERS' COMPENSATION DECLARATION <br />1 V <br />AYV:67QWAI V hereby affirm under penalty of perjury, the <br />(Namerrfae,5 , <br />following declaration: <br />I certify on behalf of f(,yh& 5 that during the term of my <br />(Cousultant/Cmn any Mame) <br />contract for 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. gg <br />DATE: I0' ` % j <br />By: <br />Name: IVAA--e,_rr ntl-eAn <br />Title: 6 fit, -t, 7 <br />Telephone: leo— 1t5r212 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SMALL 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 TIIE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />Reviewed by <br />c � <br />Carmen Acosta <br />PRCSA/Recreation <br />