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'WORKERS' COMPENSATION DECLARATION <br />- hereby affinn under penalty of perjury, the <br />(Namerritle) <br />following declaration: <br />I certify on behalf ofP-, Bpi JC�Lt during the term of my <br />(Consultant/CompanyAanie) <br />contract for N-Otl d6,yp - &r'� 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: <br />By: <br />Name: <br />Title: <br />� <br />Telephone: i -I) , 9--rt <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 COSTOF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />Re\,ke\ned bY' <br />C eNjas <br />