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WORKERS' COMPENSATION DECLARATION <br />r �1,At <br />I J_av1a, �')�" Plbereby affirm under penalty of perjury, the V� <br />tNarnc/"nncI <br />following declaration: <br />C{.kJ�tta'y� <br />I certify on behalf of q a ?t at daring the term of my <br />�� p��, (Consultrau(,ompany Nome) <br />contract for '-9 i� ��tv�� ,. -- <br />services with the City of Santa Ana, I will <br />0 -- <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_: <br />`C— By: �tZyCt��Cddll� X��lg; I <br />N'anre: i'f lak&. — <br />r-. <br />Title:jt <br />V elephorte: �C) - <br />r. <br />�� . <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 />