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CITY OF SANTA ANA <br />RISK MANAGEMENT, 4 HUMAN RESOURCES <br />Mam., ging Risk &%,vqgyf,r Positive Change <br />..... ..... ....... . .... . .... . . ....... . . ...... . ..... ....... .... . . .. ...... ..... .... . ...... .. ... .............. . <br />WORKERS' COMPENSATION DECLARATION <br />Josie Gavieres hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration: <br />I certify on behalf of BARK Therapy Dogs that during the term <br />(Consultant/Company Name) <br />of my contract for Reading Dogs 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. lt)e Awp,,- m <br />Date: September 19, 2023 <br />Print Name: Josie Gavieres <br />Print Title: Director <br />Signature. <br />Telephone: 5 . 62-235-8835 <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 />1: Risk Mgmttlnsurance Requirements I WC Declaration 08152019 <br />