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MQUERS' COMPENSATION DECLAR TION <br />I 5ervando Varela <br />W_ Y affirm under penalty of perjury, the <br />following declaration: <br />I certify on behalf of XV Solutions <br />_ that during the term of my <br />contract for mahromm aoa supponnre SC�o�r � 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: 2 j <br />Name: Servando Varela <br />Title: Owner <br />Telephone: 714-269-8190 <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 />l(tvlh�f""WED & APPROVED <br />By Ris h Ki N,10EMENT DIVISION <br />09 Mfg <br />1A M. LAMBERT <br />