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WORKERS'COMPENSATION DECLARATION <br />Ci)kj hereby affirm Linder penalty ofperiury, the <br />following declaration: <br />I certify on behalf Of that during the term of my <br />,2 (COPSURIM/Company Nwn6 <br />contra 1,01- <br />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 becorne 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 />Title: <br />Felephon )-� ,-� � I <br />e: - I -- U,, J <br />�-J 14 -� 41— <br />WARNING: FAILURE TO SECURE WORKERS, COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (SI00,000), 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 />1.10000 <br />10 <br />Gs�I <br />qlil� <br />