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WORKERS' COMPENSATION DECLARATION <br />I �Ontca (oeverso. hereby affirm under penalty of perjury, the <br />(Nameaitle) <br />following declaration <br />I certify on behalf of T 0 N A L N P� that during the term of my <br />` (C'unsultantKompnny Name) <br />contract for Vre5en'g\t on S o c4K�Y,�� 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: OD, I a a' a 01 R <br />By:�entc. - -- <br />Name: (Ac nt (. s-e v er S 1� n <br />Title: So�-aker'e5t �er <br />Telephone: (81;�O S (,?- (off f,ri <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 />