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WORKER.S'CONIPENSATION DECLARATION <br />d A 1/6 jt�ereby affirm under penalty of perjury, the <br />(Naaierrftle) <br />following dedlaration: <br />��_42z2j4LZII <br />I cortify on behalf of.. / -tant/ c)mr 24that during the term of my <br />(Conw] Any Name <br />contract for_. services wig the City of Santa Ana,l will <br />not employ any person in any manner so as to become subject to the workers- <br />competisation laws of Califoraia, 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 covcrage, <br />DATE: 17 <br />By. <br />zz- <br />Name- <br />Title: <br />Telephone: <br />WARNING: FAILUR13 TO SEGURE WORKERS' COMPENSATTON COVEMACTE, IS <br />UNLAWFUL, A NiD SHALL SUBJECT AN EMPLOYER TO CRIMINAL PFNAIXIES <br />AND CIVIL FINES UP TO ONE T-WND1.M THOUSAND DOLLARS ($100,000). M <br />ADDITION TO THE COST tali COMPENSKFION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR, CODE, INTEREST, AND ATTORNEY'S FEES. <br />A A <br />REVIEWED BY- E.U.NICEHER EDIA (p959F.5) <br />