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WORKERS' COMPENSATION DECLARATION <br />I 1 6t5IS �ArMV'Uhereby affirm under penalty of perjury, the <br />(Nama'ritle) <br />following declaration <br />I certify on behalf of N(SiS ?\A LA/lnt,I�'\ that during the term of my <br />(consults Ucompany Name) <br />contract for A 5 e/n.+t04services 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 thoseprovisionsand provide proof of workers' compensation coverage. <br />DATE: `' � i6 <br />By: <br />Name: Yv`�IS l 1�SC QV�CIG� <br />Title: 1A �1n� <br />Telephone: C��_�3Q_�1?�(p <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 />