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WQRKF:RS' COMPENSATION, PLCIARikT10N <br />[ Melina Herrera------ hereby affirm under penalty of perjury, the <br />—1 wine duel <br />following declaration: <br />I certify on behalf of ` Melina Herrera _ that during the tern of my <br />IConsullanr Company Name) <br />contract for Recreation Classes _ services with the City of Santa <br />Ana, I will not employ any person in any manner so as to become subject to the workers' <br />compensation haws of California, and agree that if I should become subject to the <br />workers' compensation provisions of Section 3700 ol'the Labor Code, I shall forthwith <br />comply with those provisions and provide proof of workers' compensation coverage. <br />DATE: <br />By: <br />Name: Melina Herrera <br />Title: Instructor <br />Telephone: 714 955-1979 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN ENIPLOYER 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 />�,aeva� <br />