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WORKERS' COMPENSATION DECLARATION <br />I Joel Hernandez hereby affirm under penalty ofpetjury, the <br />(Nai; t(e) <br />following declaration <br />I certify on behalf of Joel Hernandez that during the term of my <br />(Consu(tant/Compiny Name) <br />contract for Recreation Classes set -vices 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 Seetion 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 />o <br />Name: Joel Hernandez <br />Title: Recreation Instructor <br />Telephone: �[_111 — �� <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 />�J0 <br />