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WORKERS' COMI'ENSAT[ON DECLARATION <br />1 hereby affirm under penalty of perjury, the <br />(NamcfTitle <br />following declaration <br />I certify on behalf of 001lh SA�.gp— that during the term of my <br />(Consultant`Compaay Name) <br />contract for 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 provisions and provide proof of workers' compensation coverage. <br />DATE: M- €3 —16 <br />By: <br />Na <br />Titl <br />me: <br />e: mwd6y <br />Telephone: � `i• . <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), N <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />N SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />\a Gue�,m`r <br />g\\v <br />p�G <br />