Laserfiche WebLink
WORKERS' COMPENSATION DECLARATION <br />I, Cindy Krebs/Princinal, hereby affirm under penalty of perjury, the following <br />(Name/Tide) <br />declaration : <br />I certify on behalf of Cindy Krebs Consulting, Inc. that during the term of my <br />(Org=m ion Name) <br />contract with the Public Works Agency, City of Santa Ana, I will not employ any person <br />in any manner so as to become subject to the workers' compensation laws of California, <br />and agree that if I should become subject to the workers' compensation provisions of <br />Section 3700 of the Labor Code, I shall forthwith comply with those provisions. <br />DATE: 20 October 2008 <br />By: `6 <br />Name: l i)\ e, <br />Title: <br />Telephone: �q 1r `IH V lcti / i7f3� �7 - ,?_4 l <br />0 <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 />APPROVED A8,10 FOR14 <br />LISA E. STORCK <br />Assistant City Attorney <br />