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WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury, the <br />([�amelTit �e) <br />following declaration : <br />I certify on behalf of the term of my <br />(Consultanfl umpany Name)contractfor C t ri services with :"Zatturing <br />City of Santa Ana, I wil l <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: E5( 2— J k-1 l -. 15 -icy . <br />By: <br />Name; "P re(A '�bC4,C r <br />Title: 2)0lE; r! tbTf�eA '.... <br />Telephoner ms's- r= <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 />