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WORKERS' COMPENSA'T'ION DECLARATION <br />I Jose Romo hereby aff'inn under penalty of perjury, the <br />(,Name/Title) <br />following declaration <br />I certify on behalf of Jose Remo that during the term of my <br />(Coasultant/Comptmy Name) <br />contract for Fiestas Patrias 2016 services with the City of Santa Ana, I will not employ <br />any person in any manner so as to become subject to the workers' compensation laws of <br />California, and agree that if I should become subject to the workers' compensation <br />provisions of Section 3700 of the Labor Code, I shall forthwith comply with those <br />provisions and provide proof of workers' compensation coverage. <br />DATE: _must 31, 2016 <br />w — -- <br />Name: Jose Romo <br />Title: Consultant <br />Telephone: (714) 61.2-9227 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALT. 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 ATTORN'EY'S FEES. <br />2iN <br />�eJ�s <br />Se�G GFe1Pa��r" <br />