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CITY OF SANTA ANA <br />RISK MANAGEMENT a d&w4a 4 HUMAN RESOURCES <br />WORKERS' COMPENSATION DECLARATION <br />Steven P. Nero <br />(Name/Title) <br />following declaration: <br />hereby affirm under penalty of perjury, the <br />certify on behalf of Ultimate Attractions LLC _ that during the term <br />(Consultant/Company Name) <br />of my contract for Inflatable Rentals _ 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 />Date: 06/16/2022 <br />Print Name: Steven P. Nero <br />Print Title: President <br />Signature: /0 /(/Q <br />Telephone: 714-231-2779 <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 />kkRisk Mgmtklnsurance Requirements kWC Declaration 08152019 <br />Risk Muaigmad DMs� <br />E <br />o N,`P' REVIEWED & APPROVED BY: <br />'�--'Rfsk Management Specialist <br />