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WORKERS' COMPENSATION DECLARATION <br />I �e�w <br />hereby affirm under penalty of perjury, the <br />afollowing decla <br />I certify on behalf of�t u-i��. o that during the term of my <br />(Coosulu3nt/Company Naft <br />contract for 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 provision <br />s and provide proof of workers' compensation coverage. <br />DATE: � � <br />By: <br />Name: i/ a 9724 643P -(R, <br />4 y�( , <br />Title: A `&A -a <br />Telephone: -Qg'�f ° t? 9 ��c <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 O17E 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 />i <br />ty. iqueosales i <br />