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WQRKE, ' COMPEDATS ION DECLARATION <br />�hereby affirm tinder penalty ofperjury, the <br />(Namn/'rille) <br />following declaration: <br />I certify on behalf of that during Che term of my <br />(Consultee �ompany Name) <br />contract for fresA�C' oLbyi Ca _ 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: z 1l r f <br />By; t GvuL % f1.. <br />Name:11,r'lc S <br />Title: <br />Telephone:(? 'w` 0� _, <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 />1N SECTION 3706 OF THE. LABOR CODE, INTEREST, AND ATTORNEY'S FEES, <br />