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WORKERS' COMPENSATION DECLARATION <br />hereby affirm under penalty of perjury, the <br />(Nam¢/iac) <br />foilowin- declaration: <br />I certi fy on behalf of ffi t/-�/L/ �<yr a��that during the term of my <br />—' (Consultant/Company Nam) <br />contract for Recreation Classes services with the City of Santa Ana, I will <br />not employ any person in any manner so as to become subject to the workers' <br />compensation laws of California, and agree that if 1 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: z o i q <br />Bv: <br />Name: <br />Title: C✓fi ✓ jilZ <br />Telephone: %y V 2fl-i <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 />