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ICk/ A) / �!t?rry r of 1 hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration <br />I certify on behalf of e v ( that during the term of my <br />t (Cos t Company Name) <br />contract for ,]�� u� � ;ylt 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: 1 1 <br />Dame: G -r2 ; n.1 I) 0 ,,n I - n <br />r <br />Title: P �e- "/c ,4e c�'�-y <br />Telephone: 7) y 2--J-So j <br />11 W1401PO 1: ! • <br />• • ' • � L, ! t 111 f 11 <br />