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WORKERS' COMPENSATION DECLARATION <br />I _Patrick Hurley` hereby affirm under penalty of per jury, the <br />(*Tamo/Title) <br />following declaration: <br />I certify on behalf of Recreation Classes_ that during the terra of my <br />(consultanVcompany dame) <br />contract for guitar class— services with the City of Santa Ana, I will not employ any <br />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 3700 of th.e Labor Code, I shall forthwith comply with those <br />provisions and provide proof of workers' compensation coverage. <br />DATE: 3/20/17„ <br />Signed By: <br />Name: Patrick Hurley <br />Title: ° , ka i' ti ,-, 3 �T i c.W <br />Telephone: A) J <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 FEES. <br />