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N-2018-011 <br /> WORKERS' COMPENSATION DECLARATION <br /> I �a c k Sq„ie s hereby affirm under penalty of perjury,the <br /> (Nume/ritle) <br /> following declaration : <br /> I certify on behalf of .r , ,hc _ that during the term of my <br /> (Conaulient/Cnmpnny Name) <br /> contract for p i mne edaa s 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: X2/ 12 <br /> By: <br /> Name: l^'lesrtc Sawn <br /> Title: owtAtr <br /> Telephone: 71H- 7SS-7©(8 <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 /> aye <br /> • <br />