Laserfiche WebLink
WORKERS' COMPENSATION DECLARATION <br />I (_'�KL i0i4LS hereby affirm under penalty of perjury, the <br />(NamefriUe) <br />following declaration <br />I certify on behalf of O imb-.L�- that during the term of my <br />110001111 mpuy Nam.) <br />contract for VM& services with the City of Santa Ana, l 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:Z I�S <br />Name: CAO -Wine ka. ,VOS <br />Title: VW A-eA' <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 DOLLAR I��yOO,000). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGEIC4ti VIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST 71TTORNEY'S FEES. <br />A <br />'Go�tia <br />