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N.2 p'8,225 <br />WORKERS' COMPENSATION DECLARATION <br />I TeAcm6Aw- 5VMMi)&1hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration <br />I certify on behalf of rr-*-1q6dW6- SC6tN01t t that during the term of my <br />(Cmtsulmnt/Company Name) <br />contract for l3drt�>t1Bre,T a, i ��-fi$� 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 />1-I �i act <br />DATE: <br />lei <br />By: - <br />Name: 1 c 9 u-M 5arti5 d- 5oi3k0tlr t( <br />Title: 0\115TK Lf c,,Tor, <br />Telephone: GIG 677-1 � 3 <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 />