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WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury, the <br />�. amaTi e) <br />following declaration <br />I certify on behalf of f fSt rnkLA)11L-DQt1.lg that during the term of my <br />(consdY .) <br />contract for P54J�fTt�/JlA 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 provi ions and provide proof of workers' compensation coverage. <br />DATE: <br />By. <br />Name: �! <br />Title: "—O <br />Telephone: / <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRM41NAL 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 />eaay� <br />L7I� <br />R0m`�`. <br />P�GSP <br />