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WORKERS' COMPENSATION DECLARATION <br />'U cx-u- (4C �fL��2c�Q <br />I 6C� �`Q/y`Whereby affirm under penalty of pedury, the <br />(Namerrille) <br />following declaration <br />I certify on behalf of NXR2NA 5it-f""$ that during the term of my <br />(ConsulunHCompmy Nmne) <br />contract for pX)t2Mfti A 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 prv;ionsisand provide proof of workers' compensation coverage. <br />DATE: 3 <br />By: <br />Name: <br />I_ uLZA <br />t� <br />� <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 OP COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />Q�G <br />