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WORKERS' COMPENSATION DECLARATION <br />I %a hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration: 5 <br />I certify on behalf of_jL i <br />o of my -g, aY <br />(Organization Name) <br />contract with the Community Development Agency, City of Santa Ana, I will not employ <br />any person in any manner so as to become subject to the workers' compensation laws of <br />California, and agree that if I should become subject to the workers' compensation <br />provisions of Section 3700 of the Labor Code, I shall forthwith comply with those <br />provisions. <br />�T <br />DATE: 2/S D <br />By: �— <br />Name: /��� L/ -F <br />Title: <br />Telephone: <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 <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />