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WORKERS' COMPLNSAI ION DLCLARA I ION <br />I hereht aIfirm under penalty of perjury, the <br />r 4�me 1 itle� <br />following, declaration <br />1 ecrtify on behalf of that during the term of my <br />' — <br />Ililflll�ld111 ( 111�911\ �.�II\il <br />contract for sen ices w ith the City of Santa Ana. I wil I <br />.1.3s� h a <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 prov ide proof of workers' compensation coverage. <br />DATE: 1L <br />By: <br />Name: 4 <br />Title: <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 OP 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 />