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CITY 0I SANTA ANA <br />RISK MANAGEMENT d&ae" 4HUMAN RESOURCES <br />Managing Risk e„ wgh Positive Change <br />WORKERS' COMPENSATION DECLARATION <br />LARRY GONZA T <br />(Nomelritle) <br />following declaration: <br />hereby affirm under penalty of perjury, the <br />I certify on behalf of COYOTE INDUSTRIAL FABRICATION that during the term <br />(Consultant/Company Name) <br />of my contract for IWILLITS&SULLIVAN ARTPROJECT services with the City of Santa Ana, <br />(Type of service provided) <br />I will 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 the provisions and provide proof of workers' compensation coverage, <br />Date: a/3/2o20 <br />Print Name: LARRYGONZALEZ <br />Print Title: <br />Signature: <br />Telephone: 714-371-8919 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND <br />SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED <br />THOUSAND DOLLARS ($100,000). IN ADDITIONAL TO THE COST OF COMPENSATION, DAMAGES <br />AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />RREVIEWED ANACEMp�p�SoN- <br />(*b zoza <br />ANGLE ACEbEdo <br />1:�Risk MgmtVnsurance Requirements�WC Declaration 08152019 <br />