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w o f►��e,Y�s Cram punso�d�. L�.2.ekura,�of1 <br />I _Marisca M. Secunda <br />under penalty of perjury, the <br />(Name/Title) <br />following declaration : <br />hereby affirm <br />I certify on behalf of _ Marisca M. Secundo <br />that during the term of my <br />(Consultant/Company Name) <br />contract for _Recreation Classes <br />services with the City of Santa Ana, I will not employ any <br />person in any manner so as to become subject to the <br />workers' compensation laws of California, and agree that if <br />I should become subject to the workers' compensation <br />provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions and provide proof <br />of worker <br />,'c mpe coverage. <br />DATE: <br />J/) By: <br />Name: Marisca M. <br />Secundo <br />Title: Dance <br />Instructor <br />J, � <br />�e Telephone: 714 78 1- <br />9017 p l � \e�ed <br />WARNING: FAILURE WORKERS' <br />COMPENSATION C E E IS UNLAWFUL, AND <br />SHALL SUBJECT AN EMPLOYER TO CRIMINAL <br />PENALTIES AND CIVIL FINES UP TO ONE <br />HUNDRED THOUSAND DOLLARS ($100,000). IN <br />ADDITION TO THE COST OF COMPENSATION, <br />DAMAGES AS PROVIDED FOR IN SECTION 3706 OF <br />THE LABOR CODE, INTEREST, AND ATTORNEY'S <br />FEES. <br />