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W ORKERS_' COMP FNSAf ION DEC LARAT 10 N <br />I iA/4 iT y hereby affirm under penalty of perjury, the <br />following declaration: <br />I certify on behalf of Hp/i t; c. YdG Ethat during the term of my <br />(Cnnsuhawt'nwpan Nam) ' <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: 1/3/2019 <br />By: <br />Name: Woomvunq Son <br />Title: Owner <br />Telephone: 714-537-3499 <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 />eved <br />�v <br />Siivia c-oe,18s <br />PR�S6'a,i A�rnin. <br />