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WORKERS' C'OiMPENSA'I•ION DF.�'LAfta\'PION <br />yt i) hereby affirm under penalty orpetjury, the <br />following declaration : <br />I certify on behalf of &0r rh (114u t, p that during the term of my <br />(Coils i ut Cmnpany KNIV) <br />conu•act for Recreation Classes set -vices with the City of Santa Ana, 1 will <br />not employ any person in any manner so m 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, n . <br />Name: cr-_e �, l' t? c, <br />Title: Iu C CtSC 11A (a - <br />Telephone: ' (I �5 Ti " % rw I _ <br />WARNING: FAILURE l'0 SECURE WORKERS' COMPENSATION COVERAGE IS <br />INLAWFUL, 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 TFIF. LABOR CODE, INTEREST, AND ATPORNEY'S FEES. <br />}eve' fi\n <br />