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WORKERS' COMPENSATION DECLARATION <br />I Blanca Gonzalez hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration <br />I certify on behalf of Blanca Gonzalez that during the tern of my <br />(Coosultant/Company Name) <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: Jan 29, 2019 <br />M <br />/,ate <br />Name;-IQAZ,(A P t. <br />Title: Recreation Instructor <br />Telephone: (714) 785-4015 <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 />yI <br />