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WORKERS'COMPENSATION DECLARATION <br />[ ete�M � hereby affirm under penalty of perjury, the <br />(Naine/ri[le) <br />following declaration: <br />I certify on behalf of ({adz rrr d(r ��that during the tern of my <br />(ConsulwantlCompoi Name) <br />contract for /Q veA _ 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: �J-vn� �t, 2-01& <br />M. <br />1 f/ <br />Name: <br />Title: h0i Tlr_-y <br />V Telephone: 6s1_2-`70 <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 ($I00,000). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />dvi <br />01\. <br />?a Cj$; ` p <br />