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DocuSign Envelope ID: AF339015-D469-49AD-9F1B-C9F92A8B27ED <br />CITY OF SANTA ANA <br />RISK MANAGEMENTa dw daa 4HUMAN RE50URCE5 <br />Managing Risk n rough Posfflm Change �. 9 <br />WORKERS' COMPENSATION DECLARATION <br />Howard Johnson <br />hereby affirm under penalty of perjury, the <br />(Nome/Title) <br />following declaration: <br />I certify on behalf of Howard Johnson Unlimited LLC <br />of my contract for Live Performance <br />(Consultant/Company Name) <br />that during the term <br />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 />Date: 6/13/2022 <br />Print Name: Howard Johnson <br />Print Title: CEO <br />y: <br />Signature:U <br />bWA � Wm, <br />Telephone: s1��41?d 3__ <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 ADDITIONAL TO THE COST OF COMPENSATION, DAMAGES <br />AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />1: Risk Mgmtllnsurance RequirementsJWC Declaration 08152019 <br />q • �i <br />RlskMV%WwDMd <br />REAEwED&APPRcvEDBY: <br />A+� Auualo <br />Risk Management SpedAist <br />