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WORKERS' COMPENSATION DECLARATION <br />I &L"— SO Y01F7iA EXtt_oL V?, hereby affirm under penalty of perjury, the <br />(Name/Title) P�Ye G <br />following declaration: <br />I certify on behalf of L,P,vi�n C M,Sb 6 f c k ap, MPW(6hat during the term of my <br />(Organization Name) <br />contract with the Community Development Agency, 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: 0% / 25/20) F2 <br />By: G �' <br />Name: <br />Title: �kCGvt H ice. �t v e� 1zw <br />Telephone: C9-`t <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 />QeJle,we,A <br />C'1• C(�u�� <br />1-1 <br />