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01/07/2017 10:36 FAX 17144566646 Law Office Don Buchanan W 0041004 <br />L <br />WORKERS' COMPENSATION D 1 ARATION <br />I Karin a 0 Campo hereby affirm under penalty orperjury, the <br />(Nemdfitle) <br />following declaration <br />I certify on behalf of that during the term of my <br />(Camnit-ticompzny Name) <br />contract for Recreatlon 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: 3, r1 J 1 ri <br />By: <br />Telephone: (I [J, aii -5055 <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 />