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WORKERS' COMPENSATION DECLARATION <br />I MAu� 1' 14 k UW0 ( hereby affirm wider penalty of perjury, the <br />( ama'IWe) <br />following declaration <br />1 certify on behalf of Eou-1 o s {} f l(I Vf'� that during the term of my <br />(ConsuldMCampany Name) <br />contract for. U � services with the City of Santa Ana, l 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: <br />By: fe 1aS�in� <br />/\) <br />Name: 6 VCkif Ck <br />Title:! <br />Telephone: Aly`1 <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 ($1 00,000). 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 />ea�UU`i�. <br />e�`e� t <br />e� <br />sxk\ P� \� <br />