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WORKERS' COMPENSATION DECI ARATION <br />I TaA;t'd .� ( —_ Y' 1' J <br />hereby affirm under penalty of perjury, the <br />('Name I iuu) <br />following declaration : <br />I certify on behalf of_ �4dg 7vti- yt!aXa r -Chat during the term of my <br />(Const lmnl (ompany lanai <br />contract for Recreation Classes services with the City of Santa Ana, I will <br />not employ any person in (an) mannerso 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 ofSection 3700 of the Gabor Code, I shall forth" ith <br />comply with those provisions and provide proof of workers` compensation coverage. <br />DATE: <br />Bv: <br />Name: u w I�� <br />Title: Pelt A'A. i <br />Telephone: 3lz t`7 - <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 />