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CITY OF SANTA ANA <br />RISR MANAGEMENT, d&aQtw 4 HUMAN RESOURCES <br />Margong PJsk *mist PoWn Oungpei . <br />..e+�.�.....�.�,+--_vn•-...v+�-..+.-w+..»rw�.�rx..�..�.v..,�..vwv-w.new.�...w.eM.,......�....M.a�+.or...�._r..w+.�.w.m...-.Pm.«�..i.....—....i•.w+.u•�..�-.-r....�..�......aw .� SASSLi�. <br />WORKERS' COMPENSATION DECLARATION <br />1, Roberto Zavala - hereby affirm under penalty of perjury, the <br />(Namelr tle) <br />following declaration: <br />certify on behalf of Cosmos Event Rentals that during the term <br />(Consultant/Company Nome) <br />of my contract for Party Evens Equipment Rental services with the City of Santa Ana, <br />(Type of service provided) <br />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 />D8t6: 01 /14/2022 <br />Print Name: Roberto Zavala <br />Print Title: owner <br />Signature: GM4& <br />Telephone: 714-559-638 <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 />1:1Rlsk MgmtVnsurance Requlrementsti WC Dedaratlon 08152019 <br />flRlsk Mwwg=w1 DMsum <br />REVIEWED & NPROVED BY. <br />'a <br />-.----� Risk ManagementAnalyV <br />