Laserfiche WebLink
I, <br />CITY OF SANTA ANA <br />RISK MANAGEMENT dwaat 4HUMAN RESOURCES <br />Managing Risk owwgh PosttJve Change <br />WORKERS' COMPENSATION DECLARATION <br />Austin Quach <br />(Name/Title) <br />following declaration: <br />I certify on behalf of Qing Wei <br />hereby affirm under penalty of perjury, the <br />that during the term <br />(Consultant/Company Name) <br />of my contract for Lion Dance Performance 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: 9/2/2022 <br />Print Name: Austin Quach <br />Print Title: CEO <br />Signature: Am4ti+v(Z"d-tl <br />Telephone: 714-766-2943 <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 ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTnRn v,c GGGc <br />gam_-�., xmaMma�nvSDbidort <br />e$-',•`:': "_._ REVIEWEafi App OvEDSV <br />®, Risk Management Sup <br />!: )Risk MgmtVnsurance RequirementsJWC Declaration 08152019 <br />