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CITY OF SANTA ANA <br />RISK MANAGEMENT . 4.&,4. 4 HUMAN RESOURCES <br />Managing Risk away✓, Posltive Change , <br />WORKERS' COMPENSATION DECLARATION <br />I, VTv%,�U hereby affirm under penalty of perjury, the <br />(Name/7itle) <br />following declaration: <br />I certify on behalf of tiAvi ig ,Oo utA, that during the term <br />(Consultont/Company Name) <br />of my contract for Recreation Classes services with the City of Santa Ana, <br />(Type of service provided) <br />I will 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 the provisions and provide proof of workers' compensation coverage <br />immediately. <br />Date: <br />rl-lT-2oli <br />Print Name: <br />Print Title: <br />Signature: \ /� <br />Telephone: �- <br />-11 N 2 C-7 -7 Div i <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND <br />SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED <br />THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />VED & APPROVED <br />MANAGEMENT DIVISION <br />132020 <br />I:1Risk Mgmtllnsuronce Requirement4WC Declaration 08152019 SAMANMA <br />M. LAMBERT <br />