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RW MANACEMENTa 4ow4w aj'Hk*m I Flisc�zac s <br />IMi1A� � ays�p�lr�IMlll Ci1�11�b <br />WORKERS' COMPENSATION DECLARATION <br />I Salomon River <br />hereby -affirm under penalty of perjury, the <br />f.gavr .1rlrrfi,l <br />following declaration: <br />I certify on behalf,of Sallornon Rivera <br />fCurar,u«tu!tt�,FCtx�ti�r:y twr�r�,I <br />that during the terra <br />of my contract for Dame . _ services withthe City of Santa Ana, <br />frFw of <br />I will not employ any person in any manner SO as to become subject to the workers' <br />compensation taws of California, and agree that if I should become subject to the <br />workers` compensation provisions of Section 3700 of the Labor Cade, I shall forthwith <br />cornPly with the provisions and provide proof of workers' compensation coverage <br />immediately, <br />June 10, 021 <br />Print Salomon Rivera <br />Print Title: Rance Instructor <br />Signature: <br />Te?ephone <br />�1 471 3$204 <br />WARNING, FAILURE TO SEcu,?E WORKERS' COMPENSATION COVEFtAGE IS UNLAWFUL_ AND <br />SHAI I SURJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES Ufa r� 0, E HUN'DRED <br />THOUSAND DO11.AkS (,� CO OCO}, IN ADDIT IONTO THE COST OF COMPEi'+`SAIION, 0AM,ACt,5 AS <br />PRCIVIOEO FOR IN SIeC' I ON 5706 0-- THE LASC)R =)F., INTERFST, AND A7TCIRNCY-S FFFS. <br />t��.s rr'gm<9.�nwuorcr P.ca,�.*e�:.;n,r,}7 ff �pn`crn •�+ 1a�iSc't�i4 <br />C R twEoBr. <br />Risk Management Analyst <br />