Laserfiche WebLink
45-rfYhereby affirm <br />(Name./Tikie) <br />following declaration: I certify on behalf of Vi, J eic, <br />on,ultantl <br />contract for 201 _ 0/tC2 <br />v <br />� ek,-r 0y <br />under penalty of perjury, the <br />` 34U 14 C2 that during the term of my <br />�mpany Name) <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 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: Az2-0 1 9 <br />By: \7/- <br />Name: <br />r^ <br />eaQ.j• Title: n - i e0 L�rI�Y1�'�11.J <br />c Telephone: (.j Jkl�� <br />�3�,GS�Pa <br />Q¢ <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 />lyel <br />