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WORKERS' COMPENSA'T'ION DECLARATION <br />I Jose Romo hereby affirm under penalty of perjury, the <br />(Nan,errltic) <br />following declaration <br />I certify on behalf of Jose Romo that during the term of my <br />(ConsultanUCompany Name) <br />contract for Fiestas Santa Ana 2015 services with the City of Santa Ana, I will not <br />employ any person in any manner 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 />DATE: 2 6- <br />__._ _. -__--_ <br />Name: J9S C- l!��ow-N <br />Title: CCJ IA. S i t�.ct �-- <br />Telephone: (') t ct� 6 1 2-ci' 2_ Z <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 ($100,000). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />. <br />'Reviewed by'.I i <br />Gue�as <br />,,.�� S�GSP� Pdmm <br />