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KQW_E-5-�LQL4EE LNMTlO�rL-QBCLAMTF 4 QL <br />I 5(Nam�e-/4%t oT�—�� hereby affirm under penalty of perjury, the <br />following declaration : <br />I certify on behalf of that during the term of my <br />1. <br />U Vfttolme) <br />contract for — .05rw z- VZ�� --- services with the City of Santa Ana, I will <br />I C-) <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 />n4 <br />By. <br />Nam <br />Title: <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 ($ [00,000). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OFTHL LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />