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N-2018-013 <br />W_ORKER9� CCMPENSATIONDECLARATION <br />I�_ _� �` „_„� hereby affirm under penalty of perjury, the <br />(Nan,effide) <br />following; declaration : <br />[ certify on behalf of I 0AA -'Aq k - that during the tern of my <br />(Consuliant'Compnny Namc) <br />contract for=,e 'o pE) ASSN services with the City of Santa Ana, I wi[I <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: 11-8-116 <br />By: <br />Name: <br />Title:��Sl <br />'T'elephone: 44 <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 ATT'ORNEY'S PEES. <br />yea <br />cu��a 0 <br />