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N-2018-054 <br />WORKERS' COMPENSATION DEQLA-RA,TLON <br />I Jer Qy�� �Ow��r hereby affirm under penalty of perjury, the <br />iNama"rnlc) <br />following declaration <br />I certify on behalf of &VA4.0-4C C that during the term of my <br />(Crotsnitan(l nntpany Nana) <br />contract for h.L u-X,kS� (yf ;. _ 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 />Nam <br />n <br />Title: <br />(Iio � 2gZ <br />Telephone: 1 <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 />bX\,i 1pC <br />