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WORKERS' COMPENSATION DECLARATION <br />I —7k 610Y hereby affirm under penalty of perjury, the <br />(Nemerritle) <br />following declaration: Web <br />11 <br />ebr Sir ✓ICJ° S <br />I certify on behalf of LILI that during the term of my <br />F�SCSI �Gf (Co tandcompmy arse) <br />contract for 8' �� / 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: <br />(.� r <br />By:C�/0%GZ <br />Name: V t Jeo S] -,r tlt ces <br />Title: j7 /C D f a rr-/ <br />Telephone: (( l / ��C <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 />Reviewed by: <br />Silvia Cuevas <br />PRCSA/Admin. <br />