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N-2018-010-01 <br />Ihereby affirm under penalty of perjury, the <br />(NamerTide) <br />following declaration <br />I certify on behalf of 6e-�hcv 3r LLJ- Cj,v) that during the term of my <br />(Conau <br />WmVCompmy Name) U <br />contract for recr 't—Q�Ly)(" ` services with the City of Santa Ana, I will not <br />employ any person in any manner so as to become subject to the workers' compensation <br />laws of California, and agree that if I should become subject to the workers' <br />compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply <br />with those provisions and provide proof of workers' compensation coverage. <br />DATE:L_� <br />By: <br />Name:f E r'i JC <br />Title: 0 ,una <br />( -k df <br />Telephone: 1W (9,5` 5��i� <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 />;�evieW@d by. <br />r eves <br />