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CITYOF SANTA ANA <br />RISK MANAGEMENT, dtwaten 4 HuMAN RESOURCES <br />Managing Risk pmmgh Positive Change <br />U <br />Josh Friedman hereby affirm under penalty of perjury, the <br />(Name/fl le) <br />following declaration <br />I certify on behalf of One Zero Digital Media that during the term <br />(Consultont/Company Name) <br />of my contract for Video F roduotion and Photo services with the City of Santa Ana, <br />( pe of service provided) <br />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' compensate n pt ovisions of Section 3700 of the Labor Code, I shall forthwith <br />comply with the pro islo s and provide proof of workers' compensation coverage <br />immediately. <br />Date: October 22, 2019 <br />Print Name: Jos h Fri eCil1lan <br />Print Title: Owner <br />Signature: <br />Telephone: 88-922-100 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND <br />SHALL SUBJECT AN EMP OYE TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED <br />THOUSAND DOLLARS ($ 00,0 0), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND AT_T t4E1)K&.FaEip0 vr-ij <br />1ARlsk MOmtVnsorance <br />Declaration 08152019 <br />NEE <br />M. LAMBERT <br />