Laserfiche WebLink
WORKERS' COMPENSATION DECLARATION <br />I yLQQMYUN&__, SON hereby affirm under penalty of perjury, the <br />(Nemerritle) <br />following declaration: <br />I certify on behalf of y r 571C. YO t NEAL71a tthhat during the term of my <br />(CunsulianUC"n' N mu) <br />contract for l80 px_ *W,,p__d�I¢A/A( 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: <br />Title: OWNER.+ <br />Telephone: 7/'{_-- 537-3#99 <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 />