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CITY OF SANTA ANA <br /> Risk Management a division of Human Resources ; <br /> Managing Risk through Awareness and Action <br /> AFFIDAVIT OF EXEMPTION FOR WORKERS' COMPENSATION INSURANCE <br /> I Moises Camacho {"Representative"),attest that I am an authorized <br /> (]Name and Title of Vendor Representative) <br /> representative of OC FineArt Studio ("Company"), and <br /> (ConsultantlConipany Name) <br /> possess the authority to legally bind Company. <br /> In my capacity as Representative of Company, I represent and confirm the following,as relates to the <br /> agreement between Company and City of Santa Ana, agreement number <br /> ("Agreement")to provide mural restoration ("Services"): <br /> (Services to be provided tuider agreenieut/conhact) <br /> During the course and scope of Company's agreement with the City of Santa Ana, Company will <br /> not employ any person in any manner so as to became subject to the workers' compensation laws <br /> of California,and agree that if Company should become subject to the workers' compensation <br /> provisions of Section 3700 of the Labor Code, Company shall forthwith comply with the <br /> provisions and provide proof of workers' compensation coverage immediately. <br /> If at any time it is found that Company is not adhering to any and/or all of the statements in this <br /> document and does not maintain the minimum professional liability insurance coverage as <br /> required in the Agreement, it will be considered a breach of Agreement rendering the Agreement <br /> null and void.and Company will be frilly liable for any and all damages. <br /> 2�2 <br /> Si a(ure Date <br /> Moises Camacho <br /> Print Name <br /> Art Director <br /> Title <br /> (714) 906-0920 artecamacho64aOgmail.com <br /> Coirtact]ttfonnation,i.e.,Telephone Munber and/or Email Address <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL, <br /> AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO <br /> ONE HUNDRED THOUSANT DOLLARS(S 100,000).IN ADDITION TO THE COST OF <br /> COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> INTEREST,AND ATTORNEY'S FEES. <br /> !Affidavit of Exemption for Workers'Compensation insurance 11.12.2024 <br />