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N-2018-143 <br />W0RICE16- COiiviP! 3vSAT[ON DECLARATION <br />I-_�a�,�_g._ hereby affirm under penalty of perjury, the <br />i�nnte�T'iile] <br />following declaration : <br />I certify on behalf oF__. �s- \ that during the term of my <br />(C'a0.sult9 Company �Guuc) <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 Gabor Code, I shall forthwith <br />comply with those provisions amid provide proof of workers' compensation coverage. <br />DATE: _ 15 I �t�_L <br />gy <br />Name: <br />Title: 01-0A r y 1 f <br />Telephone: � 2!� t 6 -4 014 <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 ($ O,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 PEES. <br />Q�G <br />