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w()IZKE [tS'_COLNIPENSA-11ON DLCI,&a,,V ION <br />I( hereby affirm under penalty of perjury, the <br />do <br />fo l lowing decl aratio n <br />I certify on behalf of _ �' _ that during the term of lily <br />(Canxd4intiC'tinpuny ilnms) <br />contract Por _ Racreation Classes services with the City of Santa Ana, ( will <br />not employ any person in any manner so as to become subject to the workers' <br />compensation laws of California, and atr" that iF I should L)CCOMC subject to the <br />workers' compensation provisions of Section 3700 of dic Labor Code, I shall Forthwith <br />comply with those provisions and provide proof of workers' compensation coverage. <br />DATE: <br />By: <br />7 <br />Name: <br />Title: <br />WARNING: FAILURE TO SEC:URF: AGORKERS' COMPENSATION COVERAGE fS <br />I.NtL AWFUL, AND SHALL SUBJECT AN E;NIPLOYER TO CRIMINAL PENALTIES <br />AND CIVfL, FINES UP TO ONE, t{INDRED THOUSAND DOLLARS (St00,000). IN <br />ADDITION CO THE COST Of: COMPENSATION, DANIAGES AS PROVIDED FOR <br />IN SECTION 3 706 OF TI IE LABOR CODE:. IN I ERES T. AND ATI ORNEY'S I EES. <br />