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N -2o� �.7ss <br />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: l2• ��- tl <br />Telephone- <br />56Z <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMiII�TAL PENALTIES <br />AND CIVII. 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 />,APPROVED AS TO FORM <br />� Y <br />� LiSA E. STORCK <br />assistant City At�� eY <br />4S <br />