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,KORXIZS° QQM_J1j;NSAI' NDE�QLARNFJON <br />I _Martin Torreshereby affirm under penalty of perjury, the <br />(Namefrltle) <br />following declaration <br />I certify on behalf of Martin Torres that during the term of my <br />(Cm�anitantlC.mnpa�ty Namaj <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 subjcct 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: ©i <br />- By: <br />Name; Mmtin Torres <br />Title: _Leiswe t U/ Class Instructto�r(� �7 _ <br />Telephone: _ <br />WARNING; FAILURE TO SECURE WORIORS' COMPENSATION C.OVERAOE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($I00,000). 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 />