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WORKERS' COMPENSATION DECLARATION <br />194uAte 1SR64d V4 hl IN hereby affirni under penalty of perjury, the <br />(NOL11el le) <br />following declaration <br />I certify on behalf of.�v Yt6t- that during the teen of my <br />(CunndNnuCnnymny Nxnre) <br />contract for Recreation Classes services with the City of Santa Ann, I will <br />not employ any person in any manner so as to become subject to the workers' <br />compensation Inws 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: N 1 _120�q <br />By: (id <br />etm�b11ran1lr�z <br />Title: Tzre,{,Yt�Gt O MSl 66 m t Ayr' ( <br />Telephone: I I4) q(PDjlj?I <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 (StOO,000). IN <br />ADDITION'f0'I'HE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATfORNEY'S FEES, <br />REVIEWED & APPROVED <br />By Risk MANAGEMENT DIVISION <br />AUK 302019,�--' <br />FRANCINE R. VILLAREAL <br />