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I, Josh Friedmal <br />CITY OF SANTA ANA <br />RISK MANACEMENT.e Aw 4w 4 HUMAN RESOURCES <br />Managing Risk vm4* Positive Change - <br />WORKERS' COMPENSATION DECLARATION <br />hereby affirm under penalty of perjury, the <br />following declaration: <br />I certify on behalf of.One Zero Digital Media that during the term <br />(ConsultonVCompany Name) <br />of my contract for Video roduction and Photo services with the City of Santa Ana, <br />pe of service provided) <br />I 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 Provisions of Section 3700 of the Labor Code, I shall forthwith <br />Comply with the pro isio is and provide proof of workers' compensation coverage <br />immediately. <br />Date: October 22, 2019 <br />Print Name: Josh Friedman <br />Print Title: Owner <br />Signature: <br />Telephone: 8c8-922-4100 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND <br />SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED <br />THOUSAND DOLLARS ($1 0,0 O). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS <br />PROVIDED FOR IN SECTIC N 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. <br />I:IRisk Mgmtllnsurance Requiremer�fsl t oration 08152019 <br />