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<br />WORKERS' COMPENSA nON DECLARATION <br /> <br />I hereby affirm under penalty of perjury, the following declaration: <br /> <br />I certify that during the term of my contract with the City of Santa Ana and/or the <br />Community Redevelopment Agency of the City of Santa Ana, I will not employ any person in <br />any manner so as to become subject to the workers' compensation laws of California, and agree <br />that if! should become subject to the workers' compensation provisions of Section 3700 of the <br />Labor Code, I shall forthwith comply with those provisions. <br /> <br />DATE: B- Zq- ~oor <br /> <br />~ ~A- C') I 0 b~ ~ '>>\ i-k}.j\ll0 j r:.. Co- <br /> <br />By: <br /> <br />-7 cl.. ,;." -L <br />~',mJ/t Chit"lALoJ <br /> <br />Name: <br /> <br />Title: <br /> <br />cEo <br /> <br />Telephone: <br /> <br />or 'f 9 - d,;;,J - d- 7 ~ 0 <br /> <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 IN <br />SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br /> <br />A n <br />f '",,-) <br /> <br />,~M <br /> <br />,~-_.~_.- <br /> <br />~.,~ L <br /> <br />