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WOIZICI R5' COMPENSFlTION DECLARATION <br />1 �j ��/�jereUy affirm tinder penalty of perjury, the <br />(n�tme:mi) �(JJ <br />following declaration : <br />I certify on behalf of- Nk•r_l. r rat during the tern} ot•tny <br />(Consulrn:�UCmulwn}• Nunn) <br />contract for �� �_ services with e 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: Le \ <br />By: <br />Name; �,(d_ , f V� A <br />Title: <br />Telephone: (I �kA ) ] —m � <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 (SI 00,000), IN <br />ADDITION TO TILE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />k7^OA�O�'A <br />