Laserfiche WebLink
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 dhe <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: _Cv~ FG' ~ l ~ C.~-- <br /> Name: ~ ~C )--i c k c C~; <br /> Title: C ~ ~ <br /> Telephone: ~ 4 4- ~i~--Z- ~ Z ~~c'7 <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br /> <br /> UNLAWFUL, AI~TD SHALL SUBJECT AN EMPLOYER TO CI2IlVIIIVAL PENALTIES <br /> <br /> AND CIVII, FINES UP TO ONE HUNDRED 'THOUSAND DOLLARS x$100,000). IN <br /> <br /> ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN <br /> SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br /> A$ T® <br /> - - A S't P~arne`J <br /> ~Sls <br /> a'p`t C'~'~`J <br /> <br />