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WORKERS' COMPENSATION DECLARATION <br />I ZJC=- 6-10 \h�� hereby affirm under penalty of pequry, the <br />(NamNrida) <br />following declaration: <br />I certify on behalf of I i \bk(Yi— that during the term of my <br />(Conauham/company Name) <br />contract for QL<arft-,�kloc 10=3 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: u3 q <br />i <br />By: <br />Name: S• r a r=04f1Pyc'liP(1(" �cZ� <br />Title: J()�Oi <br />Telephone:��-�%-Q�� <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 />