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WORKERS' COMPENSATION DECLARATION <br />[ (�� 5c�, hereby affirm under penalty of pedury, the <br />(NamNTltle) pwa�Gy <br />following declaration: <br />I certify on behalf o�s � C,4, "C—that during the term of my <br />(Cons J14Company Name) <br />contract for t�C.w 1 Q /yJ, 6T L(�L �ervices with the City of Santa Ana, I will <br />not ernploy 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 withthose provisions and provide proof of workers' compensation coverage. <br />DATE: <br />O <br />By: <br />a <br />Name: VC— LCPC <br />Title: 6w V r <br />Telephone:l 4) <br />WARMING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN ENQ'LOYERTO CRIMINAL PENALTIES <br />AND CIVIL FNES UP TO ONE HUNDRED THOUSAND DOLLARS (S 100,000). IN <br />ADD ITION TO THE COST OF COMPENSATION, DANIAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />eaay'. <br />,5 <br />ev <br />