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WORKERS' COMPENSATION DECLARATION <br />I cO 4Cl hereby affirm under penalty of perjury, the <br />(Namefritle) <br />following declaration: �? g <br />I certify on behalf of !� �I��UYIs that during the term, of my <br />/}_ ousulmnucompany Nance) <br />contract for CA" k t1`DG�it�tM i 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: 0 e) l /� -/- / /& <br />By: <br />1 �) <br />Name: a s Z e r o (1 <br />Title: (j) -�J 0 Qf (— <br />Telephone: :- ( LA 3-- 66 n0l SA( <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 ATTORNEY'S FEES. <br />euiewed by <br />��C)I <br />arlrlen Acosta <br />^ AI ,ecreetiOrr <br />