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WORKERS' COMPENSATION DECLARATION <br />I(�I �hereb under penalty of perjury, the <br />(Name/Title ' <br />following declaratio <br />I certify on behalf of Qf,FAg-i 43k4?42&AJ that during the term of my <br />(ConsultanWompanyN e) <br />contract for A�MZAtq&=t 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: UL 9_ct 11(4 <br />By: y j <br />Name: �/ ok64:;3e, —L <br />Title: 1 A I L d <br />Telepho e: =%9 9. /.-v7c) <br />WARNING: TAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL FINES UP TO 014E 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 />r <br />• ique osales <br />SAPL/Youth Services <br />