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WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury, the following declaration: <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 I should become subject to the workers' compensation provisions of Section 3700 of the <br />Labor Code, I shall forthwith comply with those provisions. <br />~K~~r~ <br />DATE: August 21, 2009 <br />By: _Eliot Lane communications studio <br />Name: Donnelle Koselka <br />Title: Principal <br />Telephone: 949-690-8284 <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 />ApP~t(~'iTED AS '~~ ~'®~~ <br />LISA E. STORCK <br />Assistant City Attorney <br />l ~ <br />