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N-2018-035 <br />WORKERS' COMPENSATION DECLARATION <br />Anuc �eVe osoy hereby affirm under penalty of perjury, the <br />(Namerritle) <br />following declaration <br />I certify on behalf of —� 0 W.PLN P that during the term of my <br />g} ` (ConsulinnVC'empuny Name) <br />contract for r..a0 re,karye� 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: Oa Iag dok8 <br />By:— -- <br />Name: 90 VAf (i Se d e-r s c) <br />Title: _ e.c e t e 5k" r <br />Telephone: <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 />1N SECT'ION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />