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N-2018-008 <br />WORKERS' COMPENSATION DECLARATION <br />1 r CA v E, <br />N. 2�4 v4c 4hereby affirm under penalty of perjury, the <br />(Nome/'title) <br />following declaration <br />I certify on behalf of 11614IJ7-1e, MEA1-77'f F Ye'611 that during the tern of my <br />(ConsultnnVCompany Nmne) <br />contract for — Renregtinn 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 sliall forthwith <br />comply with those provisions and provide proof of workers' compensation coverage. <br />DATE: cJliiN <br />By: (�e� , a?. �_ E HESE <br />..: <br />Title: Recreation Class Instructor <br />Telephone: v310.' � _v <Cvl 6 7 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL MES 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 />