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WORKERS' COMPENSATION DECLARATION <br />hereby affir-m under penalty of perjury, the <br />j VamriTitlel <br />following declaration : <br />[ certify on behalf of c( Wat during the term of my <br />.ConmulmnuCompany Yame) <br />contract for _Leisure Class Instruction services with the City of Santa Ana, I will not <br />employ any person in any manner so as to become subject to the workers' compensation <br />laws of California, and agree that if I should become subject to the workers' <br />compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply <br />with those provisions and provide proof of workers' compensation coverage. <br />DATE: 3D <br />Signed By: <br />Name: _ S�� cc ` <br />Title: <br />Telephone: <br />WARNNG: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, ANC SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). N <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />N SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />