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WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury, the <br />(Namerritle) <br />following declaration: <br />I certify on behalf of W N 41 (hl1 17ro 1� u www that during the term of my <br />(Consaltant/Company Name) <br />contract for Al f wwi-(— ° N.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: 21?01 u 1 lb <br />By: Wa+( WCS ?Yo TrNt)ttYv'. <br />Name: <br />Title:Y1S�✓yl.i d✓ <br />Telephone: 31. � 71 -g1)13 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SMALL 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 />3%4P/i�� <br />