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WORKERS' COMPENSATION DECLARATION <br />I Jose Manuel Garcia hereby affirm under penalty of perjury, the <br />(N"Nride) <br />following declaration <br />I certify on behalf of Jose Manuel Garcia that during the tern of nay <br />(COBOU nf/COMPM NXN) <br />contract for Fiesta Patrias 2017 Event services with the City of Santa Ana, I will not <br />employ any person in any manner so as to become subject to the workers' compensation <br />laws of California, and agree that if I should become subject to the workers' <br />compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply <br />with those provisions and provide proof of workers' compensation coverage. <br />DATE: ()% i3 1 1-7 <br />Signed By: LCrardq.— <br />Name: Jose anuel <br />Title. (S6 A qq <br />Telephone: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CR3IINAL 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 />