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WORKERS' COMPENSATION DECLARATION <br />hereby affirm under penalty of perjury, the <br />(N'7TiW) <br />following declaration <br />I certify on behalf oi'.-._-y(jjy(��((_ that during the term of my <br />(C. m,1114`omp;= mic) <br />contract for — _VV_ services with the City of Santa Ana, I will not <br />employ any perloti in any nn�so as to become subject to the workers' compensation <br />laws of California, and agree that if I should become subject to the workers' <br />compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply <br />with those provisions and provide proof of workers' compy a coverage. <br />DATE: <br />By: --- — <br />Name' - <br />'rifle: <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 LiP TO ONE I IIINDRED TI-IOUSAND 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 />ed <br />i.qo <br />ll �l r <br />u�Na �, <br />