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0Tv o aA Y7,A A lbvA <br />RtS;,q IAANACZAtW 4 4.&i-., # HkAAAN If ; <br />III lip a* +""We Omw <br />WORKERS' COMPENSATIQN DECLARA711ON <br />Salomon Rivera hereby affirm under penalty cif perjury, the <br />following declaration: <br />I certify on 'behalf cif Salomon Rivera that during the term <br />of any contract for -)once services with the City of Santa Aria, <br />I will 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 the provisions and provide proof of workers' compensation coverage <br />immediately. <br />rrllt ; June 10, 2021 <br />Print Name: Salomon Rivera <br />Print Title: lance 'Instructor <br />Telephone: (714) 713-8204 <br />WARNING, FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNi.I VVF"Ji AND <br />St'HAI I :5UBJE TAN EMPLOYER To CRIMINAL PENALTIES AND CIVIL FINES UP IO ONL HUNDRED <br />THOUSAND D0(I..ARJ5 i,5JC0,QW), IN ADDITION TO THE COST OF COMPLNSAIlC, N. OAM.AG( SAS <br />PROVIDED FOR IN SECTION .S706 OF THE LASOR CODF, IN7rFRFST, AND ATTORNFY'S YFES. <br />1,4 k tr?gmi9lnw+orse Rr +t rn,tsi.;c u�4nGrrt p C9iS2rAi.' <br />R Rl8kMVW9VAadDMs1on <br />REMEWM&A-MMED9Y: <br />��—�' Rlsk Management Analyst <br />