Laserfiche WebLink
WORKERS' COMPENSATION DECLARATION <br />I, Rodolfo Cazales dba Toyama Karate -Do, hereby affirm under penalty of <br />perjury, the following declaration : <br />I certify on behalf of Toyama Karate -Do that during the term of my <br />(Consultant/Company Name) <br />contract for Karate Classes services with the City of Santa Ana, I will not employ any <br />person in any manner so as to become subject to the workers' compensation laws of <br />California, and agree that if I should become subject to the workers' compensation <br />provisions of Section 3700 of the Labor Code, I shall forthwith comply with those <br />provisions and provide proof of workers' compensation coverage. <br />DATE: <br />Title: <br />66w, -met -Telephone: 2j Y <br />1 <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, 4"!i'1TORNEY'S FEES. <br />