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WQRMR.S' COMI'ENSATIpN DECLARATION <br />I %PXIv4kio-S� hereby affirm under penalty of perjury, the <br />following declaration : <br />I certify on behalf of tab- that during the term of my <br />R (ConsoRwtiComWy Namo) <br />connet for oy6u 1' Get 1 V,0 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 />BATE: , _ ��Y ��(� <br />By: L ► t� "�t�1til �. <br />Name: C6wtf12. �tt'yaS <br />Title-,� <br />Telephoner <br />WARNING. FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL PINES UP TO ONE HUNDRED THOUSAND DOLLAR 100,000). IN <br />ADDITION TO THE COST OF COMPENSATION, DAAkggtI�ELi FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTERESTORNEY'S FEES. <br />A. <br />