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N-2019-004 <br />�n WORKERS'•COMPENSATION DECLARATION - <br />I hereby affirm under penalty of perjury, the <br />following declaration: / I certify on behalf of 664 I �t during the term of my <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 prc <br />comply with th . e pr visit <br />DATE: <br />of Section 3700 of the Labor Code, I shall forthwith <br />and provide proot•of workers' compensation coverage. <br />By: <br />Nam <br />Title <br />Telel <br />�ro z <br />WARN LNG: 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 T14E COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR. CODE, INTEREST, AND ATTORNEY'S FEES. <br />