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ereby affirm Linder penalty of perjury, the <br />following declaration ; <br />I certify on behalf pf �L'� ' ' r �k�E (^ that during the term of my <br />C'� aultan[(C mp( any Name) <br />contract for���/ 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 1 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: <br />L7 <br />By: <br />Name: <br />�a Title: ((1� _ (/i j C (r p5jr erlti� <br />e�Ne � 'e�b Telephone: �% I <br />Gee��• <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 />J� <br />G <br />