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WORKERS' COMPENSATION DECLARATION <br />I John Kolak hereby affirm under penalty of perjury, the <br />(Name?Isle) <br />following declaration: <br />I certify on behalf of praxis corporation that during the term of my <br />(Conmlmm!Company Name) <br />contract for electrical safety Trainingservices 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 1 should become subject to the <br />workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwitb <br />comply with those provisions and provide proof of workers' compensation coverage. <br />DATE: October 20, 2016 <br />0 <br />Name: John J. Nolak <br />Title: President <br />Telephone: 817-579-0004 <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). M <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 />