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N-2018-113 <br />WORKERS' COMPENSATION DECLARATION <br />Com,X'" hereby affirm under penalty of perjury, the <br />(Name Title) <br />following declaration <br />a l�+sI\\�)aV)c <br />I 001-tify on behalf of `I 1� �{it 4C t�\'during the term of my <br />(C'onsulmnt,Compnny Name) <br />contract for Recreation Classes 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:llo�l ✓ <br />By: <br />Name: t 1 < A 3 <br />Title: (77Y1P / <br />Telephone: " �"--7 -19 <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 14UNDRED THOUSAND DOLLARS ($100,000), IN <br />ADDITION TO THE COST OF COMPENSATION, DANIAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />