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N-2018-009 <br />WORKERS' COMPENSATION DECLARATION <br />I &IfAl HtWAJ4 hereby affirm under penalty of perjury, the <br />(NwnvTitfe) <br />following declaration <br />I certify on behalf of kw/A'1 f'i'i hyv, that during the term of my <br />(Cmuunanl/Company Name) <br />contract for A / 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: 11/7/), a/G <br />By: L <br />Name: <br />Title: ,bi 6c -!G .IAJ NP V L 7r& <br />Telephone: 70-262- <br />WARNING: <br />0-LEL <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 />N SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />Reviewed bry� <br />Silvia Cuevas <br />c)RC,SAIAdmin <br />