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CITY OF SANTA ANA <br />RISK MANAGEMENT a d&,&e a 4 HUMAN RESOURCES _ <br />M.mnging Risk y„txw� Posittve Change <br />WORKERS' COMPENSATION DECLARATION <br />Mitch Goldberg on behalf of Beginners Edge Sports hereby affirm under penalty of perjury, the <br />(Nome/Title) <br />following declaration: <br />I certify on behalf of Mitch Goldberg/Beginners Edge Sports that during the term <br />of my contract for <br />(Consultant/Company Name) <br />Recreation classes services with the City of Santa Ana, <br />(Type 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' compensation provisions of Section 3700 of the Labor Code, I shall forthwith <br />comply with the provisions and provide proof of workers' compensation coverage <br />immediately. <br />Date: 12/16/2020 <br />Print Name: Mitchell Goldberg <br />Print Title: Owner <br />Signature: Wk&" V&t&'A!i 4 <br />Telephone: 602-301-61 1 <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 ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />& APPROVED <br />1GEMENI DivisiON <br />132020 <br />I: iRssk Mgmtllnsurance Requirements) WC Declaration 09152019 <br />