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'WQRXERS� COMPENSATION DECLARATICYN <br />I W'k hereby affirm under penalty of perjury, the <br />(Narne/Tide) <br />following declaration: <br />I certify on behalf of —0J i Mb -— --- that during the term of my <br />(ConsuftmVCompany Name) <br />contract for 006�k services with the City of Santa Ana, I will <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 />WINNER I <br />DATE <br />By: Vo—,::7— <br />Name: CAfWne- I VOLS <br />Title, Ovi <br />Tel phone: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO C111MINAL PENALTIES <br />AND CIVIL FINES UP TOONE 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 ATTORNIEY'S FEES. <br />