Laserfiche WebLink
L�L <br />L, �\K A <br />hereby affirm wider penalty ofperjaaay,the <br />following declaration., <br />I certify on behall of _ji—ea—Loat drung the lern) of Y11v <br />(Consultant Ompaa� Is'allio) <br />contract for -vices with the City of Santa Ana, J will <br />not employ any persoll in any manner so as to become subject to the workers, <br />compensation laws of California., and agree that 11 1 shoLfid become subject to the <br />workers' compensation provisions of Section 3 700 of the Labor Code, I shall torthwitli <br />c0l"PlY witIl those provisjonswid provide P"001 of workers' compensation coverage, <br />DATE: <br />5 <br />By: c <br />Name: <br />Title: <br />I elephone: <br />W,U' NIN G. FAIL U Rk- 10 SECU � RE WORKERS � COMPEN S.A I I ON- 'OVEH-MiI. is <br />s <br />UNT-LAW-FUL, AND SHALL SUBJECTAN E-\ [PLOYER TO CRIMINAL PEXALTIE, <br />i7 <br />AND CIVIL FINES I..,P TO ONF HUNDRED <br />11 -11 -COS] <br />W SECTIONT3706 OFTHE LABOR CODE., INTERJ-ST, ANDATTORNEY'S FF.F.S. <br />