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i, <br />Roberto zavala <br />CPryoFSANTAANA <br />RISK MANAQF MENT w dlaw. 4 HUMAN REWURCES <br />Pig �d'ISk tlargap,�h to i <br />WORKERS' COMPENSATION DECLARATION <br />(Name/rltle) <br />following declaration: <br />hereby affirm under penalty of perjury, the <br />I certify on behalf of Cosmos Event Rentals that during the term <br />(Consultant/Company Name) <br />of my contract for Party Events Equipment Rental services with the City of Santa Ana, <br />(type of servlce provided) <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 />Date: 01 /14/2022 <br />Print Name: Roberto Z avala <br />Print Title: owner <br />Signature: A04"& . <br />Telephone: 714-569-638 <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 Or COMPENSATION, DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES, <br />1, t RlskMg+ntilnsurance Requlrementst WC Declargdon 08152019 <br />F44w,�a R, k" <br />Ruk ManagementAnayst <br />