Laserfiche WebLink
WORKERS' COMPENSATION DECLARATION <br />I _Kevin Dalrymple hereby affirm under penalty of perjury, the <br />(Nametritln) <br />following declaration <br />I certify on behalf of _Kevin Dalrymple that during the term of my <br />(Cowultant/Company Name) <br />contract for _Leisure Class services with the City of Santa Ana, I will not <br />employ any person in any manner so as to become subject to the workers' compensation <br />laws of California, and agree that if I should become subject to the workers' <br />compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply <br />with those provisions and provide proof of workers' compensation coverage. <br />DATE: - S1-Z� / -7 <br />Signed By: <br />Name: Kevin Dalrymple <br />Title: -�,Z ,& .Z.. _. 21� ),? <br />Telephone: -2 S <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 />4ze�\ �G��Patc•�' <br />5a� cgP <br />Q4. <br />