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cA. #WWWWORMW <br />T Rebeca King ____ hereby affirm under penalty of perjury, the <br />(Namalriae) <br />following declaration: <br />I certify on behalf of Rebeca King that during the term of my <br />(Coasub uVCompmy Name) <br />contract for National Anthem Fiestas 2017 Performance _ services with the City of <br />Santa Ana, I will not employ any person in any manner so as to become subject to the <br />workers' compensation laws of California, and agree that if I should become subject to <br />the workers' compensation provisions of Section 3700 of the Tabor Code, I shall <br />forthwith comply with those provisions and provide proof of workers' compensation <br />coverage. <br />DATE: <br />Signed By: <br />Name: _Reb( <br />Title: —%A - <br />Telephone: t <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 (5100,000), IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR COBE, INTEREST, AND ATT'ORNEY'S FEES. <br />Q�G <br />