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WDRKU0 QQZI IES <br />-M. —A <br />1 11,2� &L px6reby of tinder penalty ol'perjury, the <br />following declaration; <br />I certify on bobalf of '.'0 1 1) that during the torm of my <br />cOntlaot for <br />services with the City of Santa Ana, I will <br />not employ any person in any mamierso as to become snlrjuct to the worke"', <br />con,I)e1isatiot laws of California, and agree that if I should become subject to the <br />workers, compensation provisions of Sortion 3700 of the Labor Code, I shall fbilliwitIl <br />comply with those provisions and provide proof of workers' comVensanoft covomga. <br />DATE; t i– i%r t <br />By: <br />14,, <br />Name: ------ <br />L 01 <br />Title: <br />Telephone: -z— <br />WARNING FM LURE TO SECURE WOE1( lEmS, COMpENqATION COVERA(Iri IS <br />UNLAWFUL, AND SHALL RTBJECTAN EMPLOYERTO CRIMINAL PENALTIES <br />AND CIVIL FINESUPTO ONE HUNDREDTI-IOUSAND DOLLARS ($100,000), IN <br />ADDITION TO THE COST' OF COMPENSATION, DAMAGES AS PROVIDE'D FOR <br />IN SECTION 3706 OFTITELABOR CODE, INM-MEST, AND ATTOMY'S FEES, <br />