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WORKERS' COMPEN SAI ION DECLARATION <br />hereby affirm under penalty of peijwy., the <br />following declaration <br />I certify on behaffot <br />10-4iat duxing the term at nay <br />(ConsultmjCmpny Name) <br />contract for Services with the City of Santa Ana, I will <br />nal: e1uploy ally person. in any manner so as to become subject to the workers' <br />compensation laws of Califonnia, and aggree that ri'l should, become subject to the <br />workers' compensation provisions of Sectiou 3 700 of the Labor Code, I shall forthwith <br />comply with those Provisions and provide Proofot'workers' compensation, coverage, <br />DATE, <br />By. <br />N aine: -- Ale <br />Title: <br />Telephone; <br />WARNING: FAILURETO S1JJRE W010' E1,1,S'(rO1V1PENSAT1ON COVERAuE IS <br />UN .ANVIL, AND SHALL SUBJECT AN EMPLOYER TO MINIMAL PENALTIES <br />AND (1 IL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($ 100,000). IN <br />ADDIHON V0 1),-iL-COS-I'OFCOi%IPENSAlION, l.)A.N.I.A(-;ESASi)ROVII)'EDI-'Ol� <br />IN SECTION3706 OF THE LABOR CODE, INTEJT-ST,AND ATTORNE "S FEES. <br />. 006�Dl <br />\e <br />7, <br />