Laserfiche WebLink
WORKERS' COMPENSATION DECLARATION <br />((G -Owte Y� <br />hereby affirm under penalty of perjury, the <br />(Nanie/ritle) <br />following declaration: <br />I certify on behalf of CvA I W_q1R Y tq 'QRVtVO 15 that during the term of my <br />(Consultmt/Company ame) <br />contract for f) EU I�wek [, l .kUffAV � services with the City of <br />Santa Ana, I will not employ any person in any manner so as to become subject to the <br />workers' compensation laws of California, and agree that if I should become subject to <br />the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions and provide proof of workers' compensation <br />coverage. <br />DATE: 6 41 13 i 1 (o <br />Title: ('A — (9w V\A 1r <br />Telephone: 4LL- S (ccf - 1 n 38 <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 />