Laserfiche WebLink
WORKERS' COMPENSATION DECLARATION <br />hereby affirm under penalty of perjury, the <br />(NameiTitic) <br />following declaration: <br />declaration : <br />I certify on behalf of 2 t _cr- Uhat during the term of my <br />(Cans R Company Name) <br />contract for �U,� /,Y ervices 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 withthoseprovisions and provide proof of workers' compensation coverage. <br />DATE: <br />By: <br />Name: <br />Title: UwaZ-A'- <br />Telephone: 1 l <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 FIUNDRED TFIOUSAND 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 />, 044P16 <br />as <br />k� <br />