Laserfiche WebLink
N-2018-022 <br />WORKERS' COMPENSATION DECLARATION <br />I rytiVV'� L� "1l<L� hereby affirm under penalty of perjury, the <br />(Nam/Title) <br />following declaration <br />I certify on behalf of that during the term of my <br />(consultant/company Name) <br />contract for 4'r an$k.h° ^ 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: Vn / I <br />IIn <br />Name:nC� UI /n i>.1c2 <br />Title: Tra s v 17 Int ��. t— <br />Telephone: <br />�14 �� 12-G S <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 />