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WORKERS' COMPENSATION DECLARATION <br />I / 0644E F 3T� hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration: <br />�ihea S�,,dtces <br />I certify on behalf of �A, rIPPI t & that during the term of my <br />4 %5.cs/ 26' p (Cons tant/Companyt me) <br />contract for 7— / p ' za % 9 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: j ) I <br />By: 5 <br />Name: V(Jv F,,',nw Servrces <br />Title: o ('a <br />Telephone: / ( 3 <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 />Reviewed by: <br />Silvia Cuevas <br />PRCSAJAdmin. <br />