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WORKEILS' COMPENSATION DECLARATION <br />1 �.. c,+ %�e.. C C. hereby affirm under penalty of perjury, the <br />(NB,WT,[.t <br />following declaration: <br />I certify on behalfo) �L � Y `�. T. that during the term of my <br />(t'otuW MlConyany Rmnol <br />contract for _ h f. r!c, M1"t ta'f services with the City of Santa Ana, I will <br />not employ any person in any manner goes 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 <br />DATE: ,L <br />Name: <br />Title: <br />Telephone: <br />compensation coverage. <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECTAN 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 />t •. f <br />0 <br />i• ^ RosS <br />" <br />Ar - <br />