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WORKERS'COMPENSATION DECL.ARA'TION <br />I � hereby affirm tinder penalty of perjury, the <br />i�at��rrt,��1 <br />Billowing declaration: <br />I certify on behalf of 9 `-eko Goq-z"Ae-L that during the ten -A of xray <br />(ConsWtAkConTagName) — <br />contract for services with the City of Santa Ana, I will <br />not employ any persona in any manner so as to became 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 Covera ge. <br />DATE: S/�l1� <br />Name: lrl lJ r� <br />Title:+ raw r1 �rt <br />Telephone: i t `I S S S 9 2-o <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 (S 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 />