Laserfiche WebLink
WORKERS' COMPENSATION DECLARATION <br />I !stem der? A $ubanAl, hereby affirm under penalty of perjury, the <br />(Namefritle) <br />following declaration : <br />I certify on behalf of 7erem6 4 $u 4ndhl _ that during the term of my <br />(Consul�Company Name) <br />contract for 9"MiatQn—cw3 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, I shall forthwith <br />comply with those provisions and provide proof of workers' compensation coverage. <br />DATE: I -Z/13/17 _ _. _ <br />Name: Jerernb4nq (7*err'y)5u6anA <br />Title: �?g"Ct"bf <br />Telephone: ( 714 ) 6 77r 7V 7 <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 />