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WORKERS' COMPENSATION DECLARATION <br />4 <br />1 _ Q.S5icl& �r, �o ho'eby_affirm under,penalty of perjury, the <br />(NainelTitle) <br />following declaration.: <br />I certify on behalf of that during the term of my <br />(Consultapttom any Na e <br />contract for e� 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 />DATE: �� �`Z 01!7 <br />By: <br />Title: lo _ <br />Telephone: C !7 i <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 COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />a5 <br />