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WORKERS' COMPENSATION DECLARATION <br />I )aAo, affirm under penalty of perjury, the <br />(Name/Title) / <br />following declaration : <br />I certify on behalf of -Dqti b VVO(kS Thc-V that during the term of my <br />(Co y(/.1tandCompany Namc) <br />contract for 60o�le '-F <br />vsirxlYi Wo/ksticoo 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 />By: <br />/ I <br />Name: C-- rl G i LV✓ <br />Title: �VPSt Jed - <br />Telephone: 1-q 7, G -71 . 2 `6 q3 <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). 1N <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />1N SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />