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WORKERS'COMPENSATION DECLARATION <br />I Mario 06A 1 4reby affirm under penalty of perjury, the <br />(, ame:'rimc) <br />following declaration: <br />I certify on behalf ofMQ[6& M06 Y tat during the term of my <br />,% (Comulr+mtlCamrwmy Name) <br />contract for Ll� lm services with e 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 il'l should become subject to the <br />workers' compensation provisions of Section 3700 of the Labor Code, l shall forthwith <br />comply with those provisions and provide proof of workers' compensation coverage. <br />DATE: <br />By: <br />Name: M14�1G���V�- <br />Title: �njJ10p1�� fA fJ <br />Telephone: �� ��� p� g� ��V► <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SU13JECT 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 />as <br />GUe0s <br />nom,, P\RGS�Pam�n <br />