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WKQgj I,RS' COLMI E,NSATION 1713CI,ARA1'ION <br />T —Raul Martinez Qt- hereby <br />affirm under penalty of peljwy, the <br />(Name(ritla) <br />following; declaration: <br />I certify on behalf of Raul Martinez&= that during the term of my <br />(Co : n nnVCnmpany NamC) <br />contract for —Fiestas Patrias 1017 services with the City of Santa Ana, I <br />will 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: � - AY E (� I <br />Name:( ,Raul Martinez <br />Title: <br />Telephone: — <br />r Jz <br />WARNING: FAILURE TO SECURE, >I1pMI'ENSATION COV7 RACrE IS <br />UNLAWFUL, AND SHALL SUBJE& AN F00eOYER 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 />