Laserfiche WebLink
WORKERS' COMPENSATION DECLARATION <br />I _Martin Torres hereby affirm under penalty of perjury, the <br />(Name/Tllie) <br />following declaration: <br />I certify on behalf of _ Martin Tories _ that during the term of my <br />(Consultant/Compuny Name) <br />contract for _ Leisure Class Instruction_ services with the City of Santa Ana, I will not <br />employ any person in any manner so as to become subject to the workers' compensation <br />laws of California, and agree that if I should become subject to the workers' <br />compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply <br />with those provisions and provide proof of workers' compensation coverage. <br />DATE: go — / / <br />By: <br />Name; Martin Torres <br />Title: —Leisure <br />Class IIn/struuctto�rn, <br />Telephone: <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 />r�evie�ved >�y�. <br />�1d)a �uit" n <br />