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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 />DATE: ~I ~ ~.3 'O ~l ~C~~ ~l6 ~.~ ~~~~,~ r+f,, ~L <br />Name: /"~ ~ ~Z.I /~}a,/~" C ~ti '/Z% La J <br />Title: C.-~ 8 <br />Telephone: _~_y ~ -~_ 2 ~ ~ ~~ 7 ~~ <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMIlVAL PENALTIES <br />AND CIVIL FINES UP TO ONE HUNDR)E;D THOUSAND DOLLARS ($100,000). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVII)EI) FOR IN <br />SECTION 3706 OF THE LABOR CODF,, INTEREST, AND ATT'ORNEY'S FEES. <br />T~ ~'~'~ <br />AppRpVE~ AS - <br />s.~o~c~c <br />LISA ~• Attorney <br />,pssi5~ant C~~Y <br />