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WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury, the <br />(Nemernee) <br />following declaration: <br />I certify on behalf of I tAtjgftsA that during the term of my <br />11n... ham/Company Name) <br />contract for SU LTi n) (-� 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: O t — <br />By: <br />Name�j( (MC�.u�{Ey\ <br />Title: <br />Telephone: \o 'S4,�} &.C112k. <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 />RE RIEIWM D & MPPRENTpO s oD <br />