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WORKERS' COMPENSATION DECLARATION <br />I_Dru5c=r--P-Q`hLn hereby affirm under penalty of perjury, the <br />(Nameffide) <br />following declaration <br />I certify on behalf of FUant , n �n rCU that during the term of my <br />(Conn t/Compam Name) <br />contract for — 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: /3j Ile <br />By: �vcay�� v15ysCatlC� <br />Name: _ in V-t� I" <br />Title: �IYC6 G <br />Telephone: `� 1 �)-� <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 />�ed\py. <br />Rej\e Ay <br />s <br />�,eva. <br />P�. <br />