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WORKERS' COMPENSATION DECLARATION <br />I X4 4741 hereby affirm under penalty of perjury, the <br />(NumerTiUe) j <br />following declaration: 11 <br />I certify on behalf of � l� 7lX -IV that during the term of my <br />contract for l i U? 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: 9 -0/IS <br />0 <br />Name: <br />IZ-6p 9//7JFi4/ <br />Title: -4M10-W <br />Telephone: (-'/`f� V 9'1- 9 a 33 <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 />TT%r QTFrTTnTT 47nA ot+ TNp r ARnT? rnnp TNTTRRRCT ANTI ATT0PNRV'4Z RRRC <br />