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WORKERS' COMPENSATION DECLARATION <br />I Steve r+ornana.x. InsWdor <br />hereby affum under penalty of perjury, the <br />(NemeRitle) <br />following declaration: <br />I certify on behalf of WaterWiseProTraining <br />— that during the term of my <br />(Con nUComFwny Name) <br />contract for WaterUeatment and diatr butltraining <br />on t ain ng 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 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: 1 Z 101 <br />By: Name: �— <br />Steve Hemand <br />Title: Instructor <br />Telephone: 831, 75D — qll <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 (S100,000). E <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />& APPROVED <br />w.vMENT DjV1510N <br />0 2020 <br />M. LAMBERT <br />