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WORKERS' COMPENSATION DE.CLARATIO,N <br />I _ (Carlos Madriles / Ownerhereby affirm trader penalty of perjury, the <br />NnmeTnle) <br />following declaration <br />I certify on behalf of Downtown Stadium Grill that during the tern of my <br />(Collsnlfant/Company Name) <br />contract for Food & Beverage_— 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: October 1, 2015_ 7 <br />By: <br />Name: Carlos Madriles <br />Title: Owner <br />Telephone: _714-262-1441______ <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL FINES t T P 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 />