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WORKERS' COMPENSATION DEC L RATION <br />I Robin Charin hereby afiTnti under penalty of perjIury, the <br />(Nal"O ttu) <br />following declaration <br />I cerci ry on beball' of R T Clown, Inc. that during the tont of my <br />{CoosulwaWompuny N=c) <br />contract for Darks, Recreation and �G[a�xrarur�irp St�f's'iC�iS 11�,+G'tIC)r services with the City of Santa <br />Ana, I will not employ any person in any ma'irner'so as to become subject to the workers' <br />compensation laws of ialifomia, 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 eoveratge. <br />DATE: 11/14/16 <br />By <br />Nance: Rabin Charin <br />Title: Owner <br />Telephone: 310/376-2250 <br />WARNINGFAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENA T IFS <br />AND CIVIL PINES Up TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN <br />ADDl` 'ION TOO 'TETE", COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF TTIE LABOR CODE, INTEREST, AND ATromErS FEES. <br />��vas <br />