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WORKERS' COMPENSATION DECLARATION <br />I _Santiago Bautista_ hereby affirm under penalty of perjury, the <br />(Name"ritle) <br />following declaration <br />I certify on behalf of _Santiago Bautista_ that during the term of my <br />(ConsulunuCompany Name) <br />contract for _Leisure Class Instruction services with the City of Santa Ana. I will not <br />employ any person in any manner so as to become subject to the workers' compensation <br />laws of California, and agree that if I should become subject to the workers' <br />compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply <br />with those provisions and provide proof of workers' compensation coverage. <br />DATE: <br />SignedBy: <br />z -- <br />Name: _Santiago Bautista <br />Title: Kst,^c Lf. IAS tVc (W <br />Telephone: ljrl -ice r5Y� <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 />ed <br />as <br />aGOPJ�``r <br />