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4r ORICIdR ' CL7MPENSAT1 j�;BCL t R aTIO i <br />I it WrS hereby affirm under penalty of perjury, the <br />�drnm> <br />following declaration: <br />I certify on behalf of + G that during the term of my <br />( mlw atrl':mapAnY140-5) <br />contract for !- ` — services with the City of Santa Ana, I will <br />not employ any person in any marmer 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: <br />By: lI 1L1 *a e 4" <br />Name:1* <br />Title: d""": ` <br />Telephone: 60 fi-t�..�'-- w" <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 IRWORBD THOUSAND DOLLARS ($100,000). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODB, INTEREST, AND ATTORNEY'S FEES. <br />���is4lo <br />et}sib <br />