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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: f7 ~ V <br /> c <br /> sy. L~ t. <br /> Name: C -r t-~ 1 1 l~tt <br /> Title: 1>~~`(~A~.1 -~'y ~ ~~1 ~j i~l~~ <br /> Telephone: S Ll ~ E: - 2' <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 /> <br /> ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN <br /> <br /> SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br /> K <br /> ~~SA City Attorney <br /> p~sistant <br /> ~ ~ <br /> <br />