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N-2018-013' ®� <br />r+VORI<ERS' COMJ?ENSATION DEC1.1�1'vAT10N <br />I Nth hereby affirm under penalty of perjury, the <br />(vautefrl(1ul <br />following declaration ; <br />I certify on behalf of 0C)". SAAZkp= that during; the term of my <br />(Cmullant'Company Nano) <br />contract for kCdII&pTil7aCLA56E services with the City of Santa Ann, I wi 11 <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: 62.- 8 —110 <br />By; <br />Name:._^�S\�5 (mayy1R�Z /� <br />Title: <br />Telephone:. �s✓�� <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). N <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 />red <br />IF-e e . <br />�gas <br />J�aCJU �r�n <br />