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WORKERS' COMPENSATION DECLARATION <br />I _Martin Tones hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration: <br />I certify on behalf of _ Martin Torres _ that during the term of my <br />(Consultant/Company 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: 0/_ 3 0 — / / <br />By: <br />Name: Martin Tones <br />Title: —Leisure Class Instructor <br />Telephone: l ZI �) / 7 7 YLn b/ �7 <br />/ <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 />9 . etived by <br />Uey� aS <br />Ad P11dxV1\11\ <br />