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WORKERS' COMPENSATION DECLARATION <br />Isabel hereby affirm under penalty of perjury, the <br />��It <br />following declaration <br />I certify on behalf of City of Santa that during the term of my <br />il(MlsuUanWompany Name) <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 became 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: 02/21 /2019 <br />T <br />Name: Isabel Szulc <br />Title: <br />Recreation <br />instrttetrar <br />(949)246-3013 <br />Telephone: <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 (M00;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 />