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<br />AUG-14-2006 08'44 <br /> <br />CITY OF SRNTR ANA HOUSING <br /> <br />714 667 ~ ~.~2/~2 <br /> <br />N-2006-085 <br /> <br />WORKERS' COMPENSATION DECLARATION <br /> <br />I bereby affirm Wl<Ier pemlty of pajwy. the following declaration: <br /> <br />1 certify that dwing the lorm ofmy contract with th. City of Sonia Ana and/or the <br />Community Red.....lopment Agency of the City of Santa Ana. I will not employ my p<lr$0ll in <br />llIl)I manner &0 as to become subject to the worlws' compODSation law; of California, and agroo <br />llUit if I sbould become subject to tho workels' compensation provisions of Section 3700 of the <br />Labor Code, I sbAll forthwith comply with those provisions. <br /> <br />DATE,) "" /1{- Or <br /> <br />hA- 6UJ ~ <br />~ C' A. ~'-L <br />By. f--:- <br /> <br />Name: <br /> <br />MJ2<'/hsJ i1- 0/1 /'tf.?IL oJ <br /> <br />Title: <br /> <br />(' eO <br /> <br />Tclephone:--rr't -?o '( - ff If <br /> <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SBALL SUBJEcr AN EMl'LOYER TO CRlMINAL PENALTIES <br />AND CIVIL FINES UP TO ONE HUNDRED THOOSAND DOLLARS (5100,000). IN <br />ADDITION TO l1IE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN <br />SECfION 3706 OF THE LABOR CODE, INTEREST, AND ATTOaNEv'S FEES. <br /> <br />~;:\. <br />~e'" <br />~ 'l~ . <br />e-V'P~ <br />p>~~$. C ",-<,O'i'-c'f. \,oi <br />! - <.. ~ f'-\\O' <br />\-\'Of'- , C\\~ <br />'s'!>\' <br />~so;\ <br /> <br /> <br />TOTRL P.02 <br /> <br />~e 39~d <br /> <br />~l3 <br /> <br />eLSneLptL <br /> <br />~s:~t gee~/pl/se <br />