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CITY OF SANTA ANA <br />RISK MANAGEMENT aai 4 HUMAN RESOURCE5 <br />Managing Rtsk er«,gvr Pog vie Change - <br />WORKERS' COMPENSATION DECLARATION <br />I, David Salas <br />(Nome/Title) <br />following declaration: <br />I certify on behalf of Tierra Lega <br />hereby affirm under penalty of perjury, the <br />that during the term <br />(Consultant/Company Name) <br />of my contract for Performance for Tierra Legacy services with the City of Santa Ana, <br />(Type of service provided) <br />I will 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 the provisions and provide proof of workers' compensation coverage <br />immediately. <br />Date: 6/28/2023 <br />Print Name: David Salas <br />Print Title: BaUd Leader <br />Signature: ' <br />QV 4 a <br />Telephone: 626-232-8748 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND <br />SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED <br />THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />l: Risk Mgmt� Insurance Requirements �WC Declaration 08152019 <br />s.y, RIiM�t�ensiDlYldo <br />t 3 �IE1Ymd1 MFRQJ®V� p <br />gT" JACot <br />R" Managmtrnt /lnalyt <br />