Laserfiche WebLink
WORKERS' COMPENSATION DECLARATION <br />I XT_R44 5' hereby affirm under penalty of perjury, the <br />(Nnme/litle) <br />following declaration <br />I certify on behalf of �i Ic ��i �"a L(, -J C:t)n( that during; the term of my <br />(Consultmt/Company Name) <br />contract for er cul wt 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. <br />DATE: 6 -. ?o l ` '9-0 / U <br />In <br />Nam <br />Title: 0 L ji <br />FO?— r� `/ <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 AT'TORNEY'S FEES. <br />�eVlewed �� <br />cue I's <br />�rVi� <br />