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CITY OF SANTA ANA <br /> RISK MANAGEMENT.duau as HUMAN RESOURCES ..A <br /> Managing Risk m1wg*Posf�Change I. <br /> WORKERS' COMPENSATION DECLARATION <br /> Jose Cholula, President <br /> I, hereby affirm under penalty of perjury, the <br /> (Name/Title) <br /> following declaration: <br /> Lightning Youth Academy/LYRC <br /> certify on behalf of that during the term <br /> (Consultont/Company Name) <br /> of my contract for Reservation of Parks 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: 8/20/24 <br /> Print Name: Jose Cholula <br /> Print Title: President <br /> Signature: <br /> Telephone: 714-943-8975 <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 /> Risk Mwvgwiwt DMs[cn <br /> ��� REVIEWED&APPROVED BY: <br /> A. 4 Acev44 <br /> ® Risk Management Specialist <br /> I:1Risk Mgmtllnsurance Requirements�WC Declaration 08152019 <br />