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of my contract for <br />CITY OF SANTA ANA <br />RISK MANAGEMENTa d&"e[ 4HUMAN RESOURCES <br />w„ <br />Nlan,iginc7 Risk ;,r;::r;.>.: PositivO Change <br />WORKERS' COMPENSATION DECLARATION <br />Martin Torres hereby affirm under penalty of perjury, the <br />(Nome/Title) <br />following declaration: <br />I certify on behalf of Martin Torres <br />(Consultant/Company Name) <br />Recreation Classes services with the City of Santa Ana, <br />that during the term <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: /2—D2— 1�7 <br />Print Name: d1//Q i <br />/�n <br />Print Title: Recreation Class Martial Arts Instructor <br />Signature: <br />Telephone: 1 <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 />1;�Rlsk MgmtVnsurance Requirements) WC Declaration 08152019 <br />& APPROVED <br />DEMENT DiViSiON <br />�WWHIIi�: I i <br />M. LAMBERT <br />