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Jesse Nava <br />CITY OF SANTA ANA <br />RISK MANAGEMENT a daa� 4 HUMAN RESOURCES <br />ManagIt g R Jk sfix�tPoo t,t Chaq <br />WORKERS' COMPENSATION DECLARATION <br />(Name/Title) <br />following declaration: <br />certify on behalf of Super Birthday, Inc. <br />of my contract for Train Rental <br />hereby affirm under penalty of perjury, the <br />(Consultant/Company Name) <br />(Type of service provided) <br />that during the term <br />services with the City of Santa Ana, <br />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 />Date: 1-26-22 <br />Print Name: Jesse Nava <br />Print Title: President <br />Signature: <br />Telephone: 714-404-1894 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND <br />SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED <br />THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />I: Risk Mgmt�lnsurance Requirements�WC Declaration 08152019 <br />��i il�ilui . .PRa � <br />_ P <br />