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WORKERS' COMPENSATION DECLARATION <br />I pwyc hereby affirm under penalty of perjury, the <br />(Namemae) <br />following declaration: <br />I certify on behalf of tsc'fO-'O- 6 A rCE�Y B!y Az'-'y that during the term of my <br />(CamultanNCompany Nar <br />contract for F6zig i q >1- Suzy 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 sball forthwith <br />comply with those provisions and provide proof of workers' compensation coverage. <br />DATE: 6 , f <br />Name: lJAv4f- IZLAw.,,AP <br />Title: <br />Telephone: 71 `i ` W'- 336' ,!� <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 />d�01'. <br />Vol' <br />QRG <br />