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WORKERS' COMPENSATION DECLARATION <br />hereby of under penalty of perjury, the <br />following declaration <br />I certify on behalf of P that during the ten-n of my <br />(IC011SUN 1 nt/C&l pa Name <br />contract for <br />s rvices 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 />\L2Z <br />B <br />Narne;, <br />Title. <br />Telephone: <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 TOTHE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />Reviewed I* <br />-,1 � 1\jl 3' FC �,u, Pe- \\,i a �s <br />PRCSAJAdM!11- <br />