Laserfiche WebLink
WORKERS' COMPENSATION DECLARATION <br />1� +76 1; hereby affirm under penalty of perjury, the <br />(Nam tle) <br />following declaration <br />1 certify on behalf of --7e-9 A, &.z�hat during the term of my <br />(Consulwt/Company 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 1 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: <br />By:: /90 Ci v �GL44 <br />Name: y— X, le? 14i�'%� -, /) a <br />Title: C/G✓/l/�� <br />Telephone:; <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 />