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WORKERS' COMPENSATION DECLARATION <br />I Roberto Zavala 1 Owner hereby affirm under penalty of perjury, the <br />(Namenille) <br />following declaration: <br />I certify on behalf of _ Galaxy Par1l Rentals that during the term of <br />my <br />(Cozis111fdnfX01' ipany Naffie) <br />contract for Tent Rental 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 3 100 of the Labor Code, I shall forthwith comply with those <br />provisions and provide proof of workers' compensation coverage. <br />DATE: <br />fly: <br />Name: 9 <br />Title: w "tA 6 <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 ATTORNEY'S TEES. <br />