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WORKERS CONIPIiNSATION DEC°I.ARATEON <br />WaryArchiva herehy affirm under penalty of perjure, the <br />following declaration <br />1 certify on hehalf of _ Conseious Brew Inc that during the term of my <br />_ . _- <br />if nroa:I(III R omivnp Mame <br />contract for Yoga en Espanol sere ices with the Cite of Santa Ana, I will <br />not rmploc am person in anti manner so as to become subject to the workers - <br />compensation laws of California, and a,gyrec that if I should become subject to the <br />workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith <br />comply vmh those prosisiims and proy ide proofof vcorkers' compensation coverage. <br />e <br />DA hEr 02/22117 <br />t <br />Name Wary Aichilla <br />-I itle: President <br />`felcphonc: 714-663-2293 <br />WARNING: FAILURE'I'O SI CURE WORKI3RS' COMI'ENSA"I'ION COVERAGE IS <br />UN1.AWFCJL., AND SHALL SUBJE=CT AN EMPI,OYE"R TO CRiMINAt, PENALTIES <br />AND CIVIL FINFS LIP "10 ONE HUNDR[:D "THOUSAND f)OLL,ARS fSl00,000). IN <br />ADDITION TO "TI IF COST OF COMPLNSA'FION, DAMAGES AS PROVIDED FOR <br />IN SL'Cl'ION 3706 OF TELE LABOR CODE. INTEREST, AND ATTORNEY'S FEES. <br />d�� , <br />,Gk\e P <br />40 <br />991 <br />