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4WRKERS' C049PF,NSA 1'ION DECLARATIQN <br />hereby affirm under penalty ofpeijury, the <br />following declaration: <br />I certify on n behalf ofduring the torra of m}` <br />—(Cnusui�a -Coi MY Namo <br />contract for _ Recreation Classes services with the City of Santa Ana, 1 will <br />not employ an) 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 Codc,1 shall forthwith <br />eomply with those provisions and provide proof of workers' compensation coverage, <br />B Y: It// q1 <br />—'ffiv- —, <br />Name: _l <br />Title:(' " <br />Telephone: 1� <br />Z- <br />WARcNiNG: FAILURE TO SECURE WORKERS' COivIPCNSAI]ON COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CIUMINAL PEti AL' IES <br />AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN <br />ADDITION TO THE COST OF COrNIPENSA`I'ION, DAMAGES AS PROVIDED FOR <br />IN SECTION a?Ob OF THE LABOR CODE, INTEREST, AND ATTORNEY'S PEES. <br />