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CITY OF SANTA ANA <br />RISK MANAGEMENT a d&wlac 4 HUMAN RESOURCES <br />Mam,lglnq Rill :a r:; 1 Positive Change <br />WORKERS' COMPENSATION DECLARATION <br />I, Martin Torres <br />(Name/Title) <br />following declaration: <br />I certify on behalf of Martin Torres <br />of my contract for <br />hereby affirm under penalty of perjury, the <br />that during the term <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: / 2 , a2— 1�7 <br />Print Name: A in lOrce S <br />Print Title: Recreation Class Martial Arts Instructor <br />Signature: <br />Telephone: �T•71� Y97 72G' % <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 ATTORNEYS FEES. <br />I:kRisk Mgmtllnsurance Requirements) WC Declaration 08152019 <br />, <br />E 06.2020 <br />S-1\Lai�ll I 1 11. 11',';i� ;if <br />