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N-2018-072 <br />WORKERS' COMPENSATION DECLARATION <br />I _Patrick Hurley hereby affirm under penalty of perjury, the <br />(Nanieffillo) <br />following declaration: <br />I certify on behalf of _Recreation Classas that during the term of my <br />(Consultmt/Company Name) <br />contract for guitar class— 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 subj cot 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: 3/20/17. <br />Signed By: - <br />Name: _Patrick Hurley <br />Title: �_ o �� 1 1^, `3 �Tu (Apr <br />� <br />Telephone`:) <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, INTEREST, AND ATTORNEY'S FEES. <br />y <br />"a�k�g��'d�tr1 <br />Q <br />