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5/2/2019 8:10 PM FROM: Staples `1'O: +171.4571,9286 P. 6 <br />WORKLR <br />Hereby affirm under penalty ofperjury, the <br />Following declaradun <br />I certify on behalf ol'f�y�1�.j(� � that during the terns of my <br />IL urmulwnt ('unyi�ay �dnra <br />contract for Recreation Classes services witli the City of Santa Ana, I will <br />not employ any person in any mnnner so as io become subject io 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 fmiltwith <br />comply with those provisions and provide prool'ol' �� orkers' cornpensntion covcrage, <br />DATE. <br />Name: <br />Titic: _-�— <br />Telephone: 2 27 <br />WARNING; FAILURE TO SECURE WORKERS' COMPENSATION COVERALL IS <br />UNLAWFUL, AND SHALL SUBJECT AN EiMPLOYCR TO CRIMINAL PENALTIES <br />AND CIVIL FINES UP TO ONE HUNDRED ThIOUSAND DOLLARS (S100,000), IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />N SECTION 3706 01"ITIE LADOR WIDE, INTEREST, AND ATTORN[ Y'S FELS, <br />REVIEWED BY: <br />llwkgh�-11101115�1l <br />Risk Management Division <br />