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WORKERS' COMPENSATION DECLARATION <br />I IIIary Archilla hereby affirm under penalty of perjury, the <br />rNams'11Uc� <br />following declaration <br />I certify on behalf of Conscious Break Inc _ that during the term of my <br />ICna�ul4mL'Cumrain} Nazutl <br />contract for Yoga en Espanol services with the Citv 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, [ shall forthwith <br />comply with those provisions and provide proof of workers' compensation coverage. <br />DATE: 02/22/17 <br />By: <br />Nam <br />Title: President <br />Telephone: __714-653_2293 <br />WARNING: FAILURE'I'O SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIN41NAL 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 />ReJ�e� y`I <br />Y0 ON <br />GS <br />P¢ <br />