Laserfiche WebLink
WORKERS' COMPENSATION DECLARATION <br />I G Pmw � . - hereby affirm under penalty of perjury, the <br />(N—ofride) <br />following declaration : <br />I certify on behalf of ,%w?_- that during the terra of my <br />(Consultant/Company Name) <br />contract for q„ �,g ,l it :R,Fc�oAAc� a.lc�. 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: GW Lon <br />I: <br />Name: - FAjD4,9,, &AWx. <br />Title: kAIAJ <br />Telephone: <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 ATTORNEYS FEES. <br />