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CITY OF SA NTA ANA <br />R15K MANAGEMENT%HUMAN RESOURCES <br />WORKERS' COMPENSATION DECLARATION <br />AAA2r/116L /L/WNe2 hereby affirm under penalty of perjury, the <br />(Namelritle) <br />following declaration: <br />I certify on behalf of PagmlER / CSY DERV/[Ef Misr that during the term <br />(Consultont/Company Name) <br />of my contract for Pe,-r 4fa.raoV 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 />immediately. <br />Date: <br />ro- 2i-2� <br />Print Name: <br />Vice/+rE ME+ar..�Ez <br />Print Title: <br />C)W"E2 <br />Signature: <br />Telephone: <br />7/Y -7y3- 7F30 <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 ADDITION TO THE COST OF COMPENSATION, DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />I: JRisk NVmtJ1nsuronce Requirements�WC Declaration 08152019 <br />,, �wogek�onwk <br />`4 �ID6 MmOv®Bv: <br />Tau �rcreeK <br />RisklMrugmmt amvlAitle <br />