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WORK.J." 'R,S1 COMPENSATION DECLARATION <br />Carlos Madriles / Owner hereby of under pe nalty of perjury, the <br />­—­T,i-NT1m,,r i I lo <br />following declaration: <br />I certi fy on behalf of Stadium Grill-— that during the terra of my <br />(CM,Suftant/Company Name� <br />contract for _____Food & Beverage_.__ services with the City of Santa Ana, I will not <br />employ any person in any inanner so as to become subject to the workers' compensation <br />laws of California, and agree that if I should become subject to the workers' <br />compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply <br />with those provisions and provide proof of workers' compensation coverage. <br />DA'11 E: ---October I., 2015­_ <br />By: <br />Name. CaTlosMadriles <br />'Title: O-vNmer <br />'Telephone: <br />WARNING: F AfLUIRETO SECURE WORKERS' COMPENSATION COVERAGE <br />UNLA, �k'F 1JL, A ND S HALL S U BJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL FTNES (,)P'1'0 ()NE HUNDRED THOUSAND DOLLARS ($100,000). IN <br />AJANTIONTO THE COST OF COMPENSATION, DAMAGE'S AS PROVIDED FOR <br />3706 (A"T'HE LABOR CODE, INTEREST, AND ATTORNEYS FEES. <br />