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WORKERS' COMPENSATION DECLARATION <br />I _Santiago Bautista hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration: <br />I certify on behalf of _Santiago Bautista that during the term of my <br />(Consultant/Company Name) <br />contract for _leisure 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 the Labor Code, I shall forthwith comply with those <br />provisions and provide proof of workers' compensation coverage. <br />DATE: �� 17 <br />Signed <br />Name: _Santiago Bautista <br />Title: VCk 11// <br />Telephone: —ss <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 />e�4 <br />gas <br />Gee <br />S��J� gP�Pat� <br />Q�G <br />