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WORKERS' C OMPENSATION DECLARATION <br />1 5kht _ {wry q hereby affirm under penalty of peljuty, the <br />(Name Ii <br />following declaration: <br />I certify on behalf of 5a4 t f 3iZ that [luring the term of my <br />rConsnliarn'Campiny Ngmcl <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 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 Section 3700 of the Labor Code, I shall forthwith <br />comply with those provisions and provide proof of workers' compensation coverage. <br />DATE: 81G it <br />By: <br />Name: <br />Title: _ <br />Telephone: _ (G 3-- <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 AT'hORNEY'S FEES. <br />REVIEWED <br />&APPROV APPROVED <br />y ry D <br />SEP 24 201 <br />FRANC R. VILLAREAL <br />