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C1TYOrSAW A ANA <br />RISK MANAGEMENTa dturadwc 4HumAN RESOURCES <br />Managing Risk avowh Poliffive Change <br />COMPENSATION DECLARATION <br />1, <br />Josh Fri <br />following declaration <br />I certify on behalf of _Q0 Zero <br />of my contract for <br />I will not employ any <br />compensation laws ( <br />workers' compensati <br />comply with the pro <br />immediately. <br />WARNING: FAILURE TO <br />SHALL SUBJECT AN EMP <br />THOUSAND DOLLARS ($ <br />PROVIDED FOR IN SECTI <br />l: {Risk Mgmtllnsuranoe <br />hereby affirm under penalty of perjury, the <br />f • . <br />(Consultant/Company Name) <br />that during the term <br />wation and Photo services with the City of Santa Ana, <br />of service provided) <br />in any manner so as to become subject to the workers' <br />)rnia, and agree that if I should become subject to the <br />isions of Section 3700 of the Labor Code, I shall forthwith <br />and provide proof of workers' compensation coverage <br />Date: October 22, 2019 <br />Print Name: Josh Friedmann �T <br />Print Title: <br />Owner <br />Signature: ..�,.. <br />Telephone: 88_922-4100 <br />_- <br />IE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND <br />TO CRIMINAL PENALTIES AND CIVIL FIN ES UP TO ONE HUNDRED <br />)). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS <br />,6 OF THE LABOR CODE, INTEREST, AND ATTQRNEK5cF, 6ri0VI-D <br />Declaration 08152019 <br />OEM <br />