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WORKERS' COMPENSATION DECLARATION <br />I Kevin Dalrymple / Judo Instructor hereby affirm under penalty of perjury, the <br />(Namc/ridd) <br />following declaration <br />I certify on behalf of Kevin Dalrymple that during the term of my <br />(ConsulwnUCompany Nam) <br />contract for Judo Instructor_ services with the City of Santa Ana, I will not employ <br />any person in any manner so as to become subject to the workers' compensation laws of <br />California, and agree that if I should become subject to the workers' compensation <br />provisions of Section 3700 of the Labor Code, I shall forthwith comply with those <br />provisions and provide proof of workers' compensation coverage. <br />DATE: 114/2019 <br />By <br />Name: <br />Title: <br />Telephone: Yell <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 />