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WORKERS' COMPENSATION DECLARATION <br />[ (�w;�t�Lr— hereby affirm under penalty of perjury, the <br />(Namerritio <br />following declaration <br />I certify on behalf ofr:n, /C"e i that during the term of my <br />(ConsultandCompany Name) <br />contract for Recreation Classes 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: S .3 r/� <br />By: ` <br />Name: ,�/�,�,����,r✓t�g <br />Title: bn_SLrr-kzr�:: <br />Telephone: E-/ Y &)[� — zI(R-Y <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). N <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />N SECTION J706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />2: <br />