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WORKERS' COMPENSATION DECLARATION <br />I KC -A' & 1a,�� e,f hereby affirm under penalty of perjury, the <br />(Nemel'r@le) �� <br />following declaration: <br />I certify on behalf of 1,1 f, 40d 0 0 16� 46& that during the term of my <br />(Coosulto Company Name) <br />contract for rA¢44fhn �,Z/ w,,, with the City of Santa Ana, I will <br />crus vink v - <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. <br />DATE: <br />By: <br />Name: <br />Title: �fQSE�tly C <br />Telephone: 217 -30 5-5 Z qr-5 <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). N <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 />p <br />