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CITY OF SANTA ANA <br />RISK MANAGEMENT, 4wje4a 4 HUMAN RESOURCES <br />Managing Risk mrough Posture Change <br />WORKERS' COMPENSATION DECLARATION <br />Roberto Zavala <br />(Nome/Title) <br />following declaration: <br />hereby affirm under penalty of perjury, the <br />I certify on behalf of Cosmos Event Rentals <br />that during the term <br />(Consultant/Company Name) <br />of my contract for Party/Event Rental Equipment 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: 03/03/2020 <br />Print Name: Roberto Zavala <br />Print Title: Owner <br />Signature: A6a&e- a <br />Telephone: 714-569- 638 <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 />REVIEWED & APPROVED <br />By Risk MANAGEMENT DIVISION <br />APR 2020 <br />ANgiE ACEVEdo <br />l: Risk Mgmt�lnsurance Requirements � WC Declaration 08152019 <br />