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WORKERS' COMPENSATION DECLARATION <br />TrI- z hereby affirm under penalty of perjury, the <br />following declaration <br />t <br />I certify on be that during the term of my flzA—ez) <br />(Consultants ompany Naffie) <br />contract for 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 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: 7 <br />By: <br />Name: 7 <s Y- <br />Title: 0 C& /A (t�— <br />Telephone <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 ($100,000). 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 />'Viewed Vq <br />cueva S <br />',Sp,,m Adnl <br />P9,c <br />