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AOYtiCEItS' COMP RN$ATION AECIAIt ATTON <br />I 6w is' hereby affirm under penalty of perjury, the <br />utot <br />following declaration <br />I certify on behalf of 2, 1 Ce = that during the term of my <br />to„u ut1C ply Noma) <br />contract for u f't w 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 became 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 covorage, <br />DATE: 1' ti""— <br />Name: <br />Title: wE'+ <br />Telephone: , O �-� _ t Q <br />WARMING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBIECT 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 />i <br />o��`�t 9 <br />mo�j plvl tts� <br />e <br />