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WORKERS' COMPF,NSATION DECLARATION <br />I _Kevin Dalrymple____ hereby affirm under penalty of perjury, the <br />(Namdfltle) <br />following declaration: <br />I certify on behalf of Kevin Dalrymple_ that during the term of my <br />(Consulumt/Company Name) <br />contract for _Leisure Class services with the City of Santa Ana, I will not <br />employ any person in any maturer 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 />Signed By: <br />Name: Kevin Dalrymple <br />Title' S � / �- r , k, . <br />Telephone: 7 ) z� — �' z ? < 1 i <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 />