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WORKERS' COMPENSATION DECLARATION <br />James Dinh <br />(Nat idhitle) <br />following declaration: <br />hereby affirm under penalty of peijary, the <br />that during the term of my <br />(Organization Name) <br />contract with the Community Development A eg ncy, 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 />DATE: <br />I certify on behalf of <br />September 23, 2019 <br />Studiofolia <br />By: <br />Name: James Dinh <br />Title: Principal <br />Telephone: 562-841-2512 <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 TI4E COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />�e RskManagmxenfDMsian <br />g RtviimED&pAPPR,OeV,ED BY: <br />el®. .�pl �M�1YNFl R. VaCL�l1,::. <br />� Iw Risk Management A aiyst <br />