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WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury, the <br />(NamaTide) <br />following declaration: <br />I certify on behalf of I <br />_rc�tL 0" ; that during the term of my <br />(Consulmnr/Company Name) <br />contract for Recreation Classes services with the City of Santa Ana, l 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: � 31/I <br />By: <br />-- <br />r 1 <br />Title: �n_57rgL�- <br />Telephone: N / �-cl - 2-N-Y <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMNAL 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 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />