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WORKERS' COMPENSATION DECLARATION <br />f r <br />I 1 ��hezebyaft'umunderpenaltygfpezjuzy,rl� <br />�(i`iamx�JSUs) <br />following declaration: <br />I,certify on behalf of ACJ,-AAak 4N 6ll✓ that during the term of m y <br />,0 x0PASL1A% C,=R 0bMe) <br />contract for services with the City of Santa Ana, I will <br />not employ any person in any manner s`o as to become subject to the workers' <br />compensation laws of California, and agree that if I should become subject to the <br />workers' ,compensewn provisisns of Section 3700 of the Labor Codc, T shall forthwith <br />comply with those provisions and provide proof of workers' compensation <br />DATE. 6 -So -�-o 1_7 <br />By: <br />SIn <br />Title: t ✓GNc� <br />Telephone, <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL„ ANIS SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN <br />ADDITION TO TILE COSI' OF COMPENSATION. DAMAGES AS PROVIDED FOR <br />IN SECTION 3704 OF THE LABOR CORE, INTEREST, AND ed,�gRNEY'S FEES. <br />, C <br />Q�G <br />