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N-2018-074 <br />'WORKERS' COMPENSATION DECLARATION <br />I Ac. Uv;.t�j_�r hereby affirm under penalty of perjury, the <br />followin¢ declaration: <br />I certify on behalf of 41104C, Qj -icn that during the term of my <br />(Consulrmo'Compwiy Hamel <br />contract for Recreation Classes services With the City of Santa Aria, I wilt <br />not employ any person in any manner so as to become subject to the Workers' <br />compensation taws of California. and asree that if I should become subject to the <br />Workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith <br />comply with those provisions and provide proof of workers' compensation coverage. <br />DATE: 0 111,7 <br />By: <br />Name: , <br />Title: <br />Telephone:YU�G�`/ <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 />N SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />e�06 <br />