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WORKERS' COMPENSATION DECLARATION <br />I 6�fY��_ �v r1 ��i hereby affnnt tinder penalty of perjury, the <br />(Nate/'Title) <br />following declaration <br />I cert'i'fy on behalf of p* m r I r 1 m L 9 W Pg A rs41 p tl daring the term of my <br />(Consultant/Company Name) <br />contract far (IJ 1'7-11 y 1%4 U 5 t _ services with the City of Santa Ana, I will <br />not employ any person in any mariner 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: C—A-� <br />Name: <br />Title: (f,✓ <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 />