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WORKERS' COMPENSATION DECLARATION <br />I Owi"hereby affirm under penalty of perjury, the <br />(Namelritle) — <br />following declaration: ^ p 1 f <br />I ocrtify on behalf of Yi 1 D_ �.:?,, _ V �C'� L LZ - that during the term of my <br />_ (CaraultanUCampmy Name) <br />contract fore ai)S l G _ ,,,,_ 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 (should beoome subject to the <br />workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith <br />comply with �thos��pr visions and provide proof of workers' compensation coverage, <br />DATE: <br />U <br />Name: <br />Title: <br />Telephone: �- (1 ` �- r, ( `-3 :) I <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 FLUNDRED 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 />4 <br />�o-q4 <br />