Laserfiche WebLink
AORK!"'IRS'COMPE'NSATION DECLARATION <br />I tikkly A- hereby affi rin under penalty of perj nry, the <br />(Name/Tilly) <br />following declaration <br />I certify on behalf,of <br />L that durinc, the term of my <br />ACC s¢ C> <br />'onigrvicemy Name) <br />with <br />-i the City of Santa Ana, I will <br />PW 's contract for 'I <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: <br />By: <br />Name: <br />...... .... <br />Telephone: <br />WARNING: FAILURFITO SECURE WORKERS' COCA 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 ATTORNEYS FEES. <br />99, <br />