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N-2018-102-01 <br />WORKERS' COMPENSATION DECLARATION <br />I �4,(yNn`A SQXni % hereby affirm under penalty of perjury, the <br />(NanelTttle) <br />following declaration: <br />1 certify on behalf of �A 6,m I R P --(n7 (SAO that during the term of my <br />(organization Name) <br />contract with the Community Development Agencx City of Santa Ana, I will not employ <br />any person in any manner so as to become subject to the workers' compensation laws of <br />California, and agree that if I should become subject to the workers' compensation <br />provisions of Section 3700 of the Labor Code, I shall forthwith comply with those <br />provisions. <br />DATE: --- �"-� -- ------ <br />un4'nl moo\ kk CVcv, <br />By: ��>^r�� � -rr�----- <br />Name: `i y» ��1— ° Ynk -_ <br />Title: <br />Telephone: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECTAN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL FINES UPTO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGESAS PROVIDED FOR <br />IN SECTION 3706OFTHE LABOR CODE, INTEREST,AND ATTORNEY'S FEES. <br />