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WORKERS' COMPENSATION DECLARATION <br />I _Choc Le hereby affirm under penalty of perjury, the <br />(Namerride) <br />following declaration: <br />I certify on behalf of _Choc Le that during the term of my <br />(Consultant/Compmy Name) <br />contract for Recreation Class Instructor services with the City of Santa Ana, I <br />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 those provisions and provide proof of workers' compensation coverage. <br />DATE: �L <br />/16 <br />Signed By: 6zu <br />Name: Choc Le <br />Title: Recreation Instructor <br />Telephone: g 83 _ 2s80 <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 />" " "` " " " ° " CODE, INTEREST, AND ATTORNE , a FEES. <br />