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WORKERS' COMPENSATION DECLARATION <br />BlanLa_Ar.ce -eby affirm under penalty of perjury, the <br />hei nin <br />following declaration <br />I certify on behalf of <br />(Consultant'Company Name) <br />that during the term of my <br />contract for Rprrpafion classasservices with the City of Santa Ana, I will <br />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 those provisions and provide proof of workers' compensation coverage. <br />DATE: 12/7/16 <br />B y:� <br />, <br />Name: Blanca Arceo <br />Title-. Recreation Class Instructor <br />Telephone: 714 805-0592 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (S 100,000). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />M SECTION 3 )706 OF THE LABOR CODE, INTER -EST, AND ATTORNEYS FEES, <br />