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WORT{ERS' COMPENSATION DE LARATION <br />I _Santiago Bautista— hereby affirm under penalty of perjury, the <br />(Name Title) <br />following declaration <br />I certify on behalf of._Santiago Bautista that during the term of my <br />(ConsultanGCompany Nam¢) <br />contract for _Leisure Class Instruction services with the City of Santa Ana, I will not <br />employ any person in any manner so as to become subject to the workers' compensation <br />laws of California, and agree that if I should become subject to the workers' <br />compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply <br />with those provisions and provide proof of workers' compensation coverage. <br />DATE: <br />Signed By: ✓ 1,, r " <br />Name: _Santiago Bautista <br />Title: Kaft:,�- it1S'iT <br />Telephone:l� <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 (S 100,000). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION J706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />