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WQg&El� �LLQNLPLjj,�Ajj OH.IjEg_LA �LN <br />hereby affirm under penalty of perjury, the <br />following declaration: <br />I certify on behalf of that during the -term of my <br />Consult n0mpany Name) <br />with the City o <br />J) "c , " I , . I . _ <br />contract for & �` / . , services f Santa n Aa, I will <br />not employ any person in any mahner so as to become subject to the workers' <br />compensation laws of California, and agree that if I should becoine subjec:t to the <br />Nvorkers' compensation provisions of" Section 3700 of the Labor Cody-,, I shall forthwith <br />comply vOth those provisionswid provide proof of workers' compensation r coverage. <br />DATE: <br />By <br />Name: <br />Title: <br />Telephone: ... qjq:j_C,2' _Ig" ..... .. ... <br />... <br />c + e <br />