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WORKERS' COMPENSATION DECLARATION <br />I 1 k JbWG ( hereby affirm Lander penalty of perjury, the <br />(NainetTitle) <br />followh3g declaration: <br />I certify on behalf of C 1.. (evt { �Gi✓Gt 9 k ,that during the tenn of nay <br />(Gun8WtMVCan1anny Name) <br />contt-act for Cot k.lv,l cv ockoce, 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: 01 Gti 2 <br />By: 46A . <br />Nance: ��� +Ct Gi ilG� wrxL�_ <br />Title: DC{ c[= I6.1S[ruC,br tbf;r Io7GtIi � <br />Telephone! (114) 2`1 1 - 11 1 l & 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 />1N SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />