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W0.1KERS' COMPENSATION DECLARATION <br />hereby affirm under pecalry, of perjury, the <br />following declaration <br />cer^.ify on behalf of s t $" —that during the term of my <br />(^ons lr ;(7ompuny Name) <br />contract for rCly \ Q v9e ,T �12Gy ervlces with the City of Santa Ana, I will <br />not ernpley any person, in any manner so as to became 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 J 700 of the Labor Code, I shall Forthwith <br />comply with those provisions and provide proof of workers' compensation coverage. <br />DATE: <br />By: � t. <br />Name: <br />Tide: UL�-' �� T--P-- <br />c <br />Teiaphone; <br />WAR` UNG: FAILURE TO SECURE WORICE.RS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN ENQ LOYER TO CRILIINAL PENALTIES <br />AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (S [00,000'). IN <br />ADDITIONTO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION J706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />S <br />U da <br />CX <br />