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A _ f01-1_7r�s <br />" * CITY OF SANTA ANA <br />WORKERS' COMPENSATION DECLARATION <br />�COOr8ee �fh���h <br />do hereby affirm under penalty of <br />Name and This <br />perjury the following declaration: <br />I certify on behalf of Gl— that during <br />consultandCompany Name <br />the full term of my contract for performing C- e 0 A F�, VI' o,vy7 Q4rfv4ices <br />Services provided <br />with the City of Santa Ana, I will not employ any person in any manner so as to become <br />subject to the workers' compensation laws of California, and agree that if I should <br />become subject to the workers' compensation provisions of Section 3700 of the Labor <br />Code, I shall forthwith comply with those provisions and provide to the City proof of <br />workers' compensation coverage. <br />Signed Signed this date: 1 By' <br />Name <br />Position Title <br />Telephone <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND <br />CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), AND IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN <br />SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />Form - Workers Comp Exempt Declaration <br />