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WORKERS' COMPENSATION DECLARATION <br />.Ji'lLde?eby affirm under penalty of perjury, the <br />(Mont l'itiel <br />following declaration: <br />I certify on behalf of that during the term of my <br />(Con iltanLCmnpa�ry N;u�.� <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 Labor Code, I shall forthwith <br />comply with those provisions and provide proof of workers' compensation coverage. <br />DATE: <br />By: <br />Marne: vI u�Y I �i/�/��t <br />ritic:(-e�z <br />Telephon__.iC.�_�---�� o� <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 ($100,000). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, <br />SxP ��N <br />9 <br />