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WORKERS' COMPENSATION DECLARATION <br />I teremban�a674�kf hereby affirm under penalty of perjury, the <br />(NU—nirf -111w) <br />following declaration: <br />I certify on behalf ofTdrembanq sukvl(1111 that during the term of my <br />(Consul Utnf/Compmy Nme.) <br />contractfor 5alo)"Itzar) Cta� ___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: 12- /08 Az o 16 <br />By: <br />Name: Terembufoi(—lerfr� �Sjb&6indkt' <br />Title: <br />Telephone: - -77 .one: � 110 6 7I37 <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 ATTORNEYS FEES. <br />