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N -20V-010 <br />WORKERS' COMPENSATION DECLARATION <br />I &-AbQhereby affirm under penalty of perjury, the <br />(Namen'itle) <br />following declaration <br />I certify on behalf of -f±(io- 7CJ AzrfQ I that during the term of my <br />(Consultmdcompmy Name) <br />contract for recr e,0CA,161rltl �, services with the City of Santa Ana, I will not <br />employ any person in any manner so as to become subject to the workers' compensation <br />laws of California, and agree that if I should become subject to the workers' <br />compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply <br />with those provisions and provide proof of workers' compensation coverage. <br />DATE: lv1 f (0 _ J <br />By: <br />Name: <br />Title: r -t . ,t.. Y'c�-} <br />Telephone: llu '� _ <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 />ikeuiOw <br />d�y <br />Si\via Cuevair <br />c��GSP� Aim <br />