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WORKERS' COMPENSA ION DECLARATION <br />hereby affirm under penalty of perjury, the <br />(Namefri[le) <br />following declaration <br />I certify on behalf of 1C ,yy� Q(TVL C r ICJ that during the term.of my <br />cdns lltanVCompany Name) - -- <br />contract for ��. t,t c u y �� a 4 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: GI <br />By: p-,,r (c)ok �t�iclu �o�7ti (fy td'5 <br />,. <br />Name:( v <br />Title: v- S (JOcr �ii r < } <br />Telephone: <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). 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 />?-Pelw'`N ll1 <br />4 <br />Q <br />