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WORKERS' COM PEN SATION DECLARATION <br />I 4hereby affirm under penalty of perjury, the <br />�Nanici'ride) <br />following declaration <br />I certify on behalf of that during the term of my <br />(Consultatiff'onipany Name) <br />contract for n services with the City of Santa Ana, I 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: V/41 SIGN <br />By: <br />HERE <br />Name: ;eA,4,J, e <br />Title: Recreation Class Instructor <br />�3 <br />Telephone: <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 ATTORNEYS FEES, <br />