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WORKERS' COMP'ENSA'T'IO'N DECLARATION <br />I -Kevin Noonchester, ------ — hereby affirm under penalty ofperjury, the <br />(Namerl'itle) <br />following declaration: <br />I certify on behalf of -Noteworthy Puppets Inc._ that during the term of my <br />(Consultant/Company Name) <br />contract for _Puppet Show__,,_,,_, services with the City of Santa Ana, 1 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: January 8, 201.6_„__.._._- <br />i <br />Y: <br />016.......-- ­ <br />Name: -Kevin Noonchester <br />Title: -Owner <br />Telephone: _323 -524 -ST -IOW <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYERTO 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 />- 04e 6xJ1 <br />