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W" <br />ION <br />hereby affirm under penalty of pedury, the <br />(Narnefl'itlo) <br />following declaration <br />I certify on behalf of Javier Palma <br />that during the term of my <br />(Consultant/Company Name) <br />contract for Recreation Class 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: _6 <br />By <br />W <br />mme- <br />tr <br />WTitle: <br />Telephone: <br />C-5N� <br />Q el <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 T14E COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />