Laserfiche WebLink
WORKERS' COMPENSATION DECLARATION <br />I .,� hereby affirm under penalty of perjuty, the <br />lNnnaeJTit el <br />following declaration: J Q <br />✓f��/�h1�U77� /�'O.AJv�.iw/ <br />I certify on behalf of that during the term of my <br />(CGIIS14mt/Campany Name) <br />contract for L'� �n,'yA _ 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: Z - ) J <br />By: �- <br />Name: <br />Title: <br />Telephone: _ Ted,�s',�v- `i, z Z <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 />