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03/07/2017 10:36 FAX 17144589646 Lax Office Don Buchanan Ig004/004 <br />L_ <br />ORKERS' COMPENSATION DECLARATIO <br />I Karina O'Camoo hereby affirm under penalty of perjury, the <br />(N#metride) <br />following declaration <br />I certify on behalf of that during the term of my <br />(Con hlt `wcompany 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: 31 7.1Ir <br />Telephone: (I [F) 2Ji " 0 ee <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 />