Laserfiche WebLink
WORKERS' COMPENSATION DECLARATION <br />I \10 n 'P1,?«vtZ hereby affirm under penalty of perjury, the <br />(Nam"IWei <br />following declaration <br />I certify on behalf of IJL;erfV 01 LE2,t I O that during the term of my <br />(Consohant Company \mnc) <br />contract for Recreation Classes set -vices with the City of Santa Ana, 1 will <br />not employ any person in ,my 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, 1 shall forthwith <br />comply with those provisions and provide proof of workers' compensation coverage. <br />DATE: d IZ'! 11K <br />i <br />By. <br />Name: <br />Title: <br />Telephone: JI 4 '65-7-- 71101 <br />WARNING: FAILURE 1'0 SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMNAL PENALTIES <br />AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (4100,000). 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 />J fi\� <br />o�yGS�Pa <br />e�` <br />