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ad <br />WORKERS' COMPENSATION DECLARATION <br />II� <br />hereby affirm under penalty of perjury, the <br />iNamenlnci <br />following declaration: <br />N-2018-096 <br />I certify on behalf of �J.: a S�i I c that during the term of my <br />(ConsultantlCompan- Name) <br />contract for Recreation 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 shall forthwith <br />comply with those provisions and provide proof of workers' compensation coverage. <br />DATE: r 6 <br />By:f <br />Name: _ l a>u <br />Title: r S,- —,,c , t __ <br />Telephone: _� l l 55 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLANNFUL, 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 />