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WORKERS' COMPENSATION DECLARATION <br />I. -Geraldine Valencia hereby affirm under penalty of perjury, the <br />(Name/Tide) <br />following declaration <br />I certify on behalf of Geraldine Valencia _ <br />(Consultant/'Company Nme) <br />contract for Leisure Class <br />that during the term of my <br />services with the City of Santa <br />Ana, I will not employ any person in any manner so as to become sub°ject 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 Jprovisions and provide proof of workers' compensation coverage. <br />DATE: <br />� a <br />Signed By: <br />Name: _ Geraldine Valencia <br />Title: <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 />P600 <br />Q�G�P <br />