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O3/07/2017 10:36 FAX 17144569646 Lav Office Don Buchanan 4DO04/004 <br />N-2018-078 <br />L <br />� yV0 KERS' COMP�aCAT <br />� ION D r^t a u a Trn�r <br />i <br />i 1 Katona O'Camtio <br />(Name/na') hereby affirm under penalty of porjury, the <br />following declaration : <br />! eectifjr an behatf of that during the term of my <br />auimntlQompany Nem') <br />contract for Recreation i.18a5eg <br />services with the City of Santa Ana, I will <br />not employ any person in any manner so as to become subject to the workers' <br />compensation laws of California, and agree 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: � I ri I 1 r7 <br />Name: <br />Titic: �Q�f1A}10Vl��YYGG<wW _ <br />Telephone: -LI 6 211-5055 <br />WARNL40: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER To CRUYnNAL 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 />ca�G�P� <br />