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03/07/2017 10:36 FAX 17144569646 Let Office Don Buchanan 0004/004 <br />L. <br />WORKERS, CQMPEN ATIOUDZ2L& T10Ti <br />I <br />i <br />I Karroo O'Camoo hereby arrr under penalty ofperjury, the <br />ttramairi"O <br />following declaration <br />I certify on behalf of that during the tern of my <br />(ConfniunvCpmPam'Nuni} <br />contract for Recreation Classes <br />services with the City of Santa Ane, t will <br />not employ any person In any manner so as to ¢ecome subject to the workers' <br />eompensation laws of California, and agree that if I should become subject to the <br />workers' compensation provisions of Section 3700 of the Labor Coda, I shall forthwith <br />comply with those provisions and provide proof of workers' compensation coverage, <br />DATE: _ 31 r7.1 11 <br />By: <br />Name: <br />Title: {TQC ahW1_�iI�YY6fUV <br />Telephone: (IK'` 2i$ -wri <br />WARNWO: FAILURE TO SECURE WORKERS, CO;KPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRI4i ANAL PENALTIES <br />AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (S [00,000). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3 706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />C;0 <br />Q <br />i <br />