Laserfiche WebLink
w(,)Rl<F._RS�_COiyIPENSA-rION DECLARATION <br />I �L�:. hereby affirm under penalty of perjury, the <br />tu,n,u;rttfo <br />followingdeclaration: _ <br />1 certify on behalf of _/� �F � P,S R'~ that during the term of my <br />(ConsWram;Cmnpany Nome) <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: <br />By: <br />Name: / e ) r � . <br />'title: <br />Telephone: _���7 ? (_- <br />WARN MG: FAILURE TO SE.C:URE. WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EIVIPLOYER TO CRI.NIGN,AL PENALTIES <br />AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (S100,000). IN <br />ADDITION TO THE COST OF COMPENSATION, DANIAGES AS PROVIDED FOR <br />IN SECTION 3706 OF TIT. LABOR CODE. INTEREST. AND ATTORNEY'S FEES. <br />