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iVORKERS'M)EQ AItATICi I <br />I <br />Gloria Mona hereby of under malty of may, the <br />following declaration <br />I ceftify on behalf of Gloria mona that during the term of my <br />(c N) <br />contraet for Ifomwe services with the City of Sam Ata, I will <br />not employ any person in any wanw so as to become wbject to the worms' <br />compewation laws of Califomia, and agree that if I should dome sul�ect to the <br />work' compemtion provisions of Section 3700 of the Labor Code, I sly forthwith <br />comply with those provisions pride proof of wozk ' compensation coverage. <br />DATA: 502t2017 <br />By_ <br />Nom: Gloria Arjona <br />Title: Dr. <br />Telephone: (213) 9804187 <br />