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06/21/2017 16:49 FAX <br />U 005 <br />WORKERS' COMPENSATIONDECLARATION <br />I A\./ SWWA hereby affirm under penalty of perjury, the <br />(Namt(TW per• orv� f <br />following declaration <br />I certify on behalf of I(F,-xhat during the term of my <br />( onsnitant/Company Name) <br />contract for �u GO%1n� �0 l�, 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, 1 shall forthwith <br />comply with those provi Iions and provide proof of workers' compensation coverage. <br />DATE: 1 <br />By: <br />Narr <br />Title <br />Telephone: _L O <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 />eddy'. <br />�eJ\e� 3�� <br />PEGS <br />