Laserfiche WebLink
T^J' ti. <br /> .,i' 'tvL,n: ,',I',.i'';li .1 ,f!VI if,,'I ,I 1.•II:.,,., R <br /> 1\li:. ;I:i i'.i !' ,!ii :•i'i,',Il h.. , .It:f., . ; I.I;.1:. 4,M ' <br /> AFFIDAVIT OF EXEMPTION FOR WORKERS' COMPENSATION INSURANCE <br /> T, .. R /C'-; • Etti <br /> /(74- \ ,O.("Representative"),attest that f am an authorized <br /> Noma and.riile or Vendar Ropms niatIvo <br /> representative of r le 1,A t( l-4 /6 110. ("Company"), and <br /> (C'oisullnnt/Company Nome) <br /> • <br /> possess the authority to legally bind Company, <br /> In my capacity as Representative of Company, I represent and confirm the following,as relates to the <br /> agreement between Company and City of Santa Ana, agreement number <br /> ,---7) <br /> ("Agreement")to provide r Sy c= 4 'G r.c / rn- L . ("Services"): <br /> (Scrvirc::inik,provided under ngI'euwnucoturncil <br /> During the course and scope of Company's agreement with the City of Santa Ana,Company will <br /> not employ any person in any manner so as to become subject to the workers' compensation laws <br /> of California,and agree that if Company should become subject to the workers' compensation <br /> provisions of Section 3700 of the Labor Code,Company shall forthwith comply with the <br /> provisions and provide prooiorworkers' compensation coverage immediately. <br /> If at any time it is found that Company is not adhering to any and/or all of the statements in this <br /> document and does not maintain the minimum professional liability insurance coverage as <br /> required in the Agreement,it will be considered a breach of Agreement rendering the Agreement <br /> null and vo I and Co; pony will be fully liable I'or any and all damages. <br /> • t.. 44/1,4k.— I 1 //1 0 'I <br /> Sig alum Wu <br /> &---1?/ C--it ,G—( 4 IIKA------ ....___... . <br /> Print Nemo <br /> ) Sei a i <br /> / 7ltt' ____ APPROVED <br /> By Cynthia Mora at 2:01 pm, Nov 19, 2024 <br /> Contact Inl'ur,►niiion_i.e.,'1'dcphonn Number and/or Iimail Adsh'os <br /> WARN ING; FAILURE'1'0 SI:CI_JRls WORKERS'COMPENSATION COVERAGE IS UNLAWFUL, <br /> AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP To <br /> ONE I IUNDRE1.)TIIOUSANT DOLLARS(S 100,000). IN ADDITION TO T11E COST OF <br /> COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 370fi OF Tl IE LABOR CODE, <br /> INTEREST,AND ATTORNEY'S PEES. <br /> Affidavit of Exemption for Workers'Compensation insurance 11.12.2024 <br /> 9 Ic d Z£54fr` 600L6c8666t ItE.AMID 'alI £Z:£Z 6Z0Z"II'LI <br />