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N-2018-125 <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury, the <br />(Name! He) <br />following declaration <br />I certify on behalf of T*,44hat during the tern <br />(Consu ant/Company Name) <br />contract for Recreation Classes services with the City of Santa Aria; <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 th <br />workers' compensation provisions of Section 3700 of the Labor Code, I shall foi <br />comply with those provisions and provide proof of workers' compensation cove <br />DATE:/201 Eoi b' <br />By: 6 K <br />Name:�G0�r. <br />Title: D� irw <br />Telephone: <br />WARNING: FAILURE TO SECURE WORKER', <br />UNLAWFUL, AND SHALL SUBJECT AN EMP: <br />AND CIVIL FINES UP TO ONE HUNDRED TH <br />