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WORKERS' COMPENSATION DECLARATION <br />I —�v-,�n flvl'tc do hereby aftinn under penalty of perjury, the <br />(Nmme,Tille) <br />following declaration: <br />117 - �( <br />I certify on behalf of TT ufqz c 0 that during the term of my <br />(ConsutrunUCompany Name) <br />contract for �I de /vlu S� O 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 Califomia, 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: �f I 2 l 0 n <br />By: <br />Name: �Uetrlu( �UO <br />Title: Mue,'c (AVr1 <br />Telephone: (7) 1 ) 5 6 1 -r5 1 7 6 <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 />