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CITY OF SANTA ANA <br /> RISK MANAGEMENT a dLc,� HUMAN RESOURCESsa <br /> �Wotla IIIc) Rich; poi itivc C:ha11gc° <br /> WORKERS' COMPENSATION DECLARATION <br /> Josie Gavieres _ hereby affirm under penalty of perjury, the <br /> (Name/Title) <br /> following declaration: <br /> certify on behalf of BARK Therapy Dogs _ that during the term <br /> (Consultant/Company Name) <br /> of my contract for Reading Dogs services with the City of Santa Ana, <br /> (Type of service provided) <br /> 1 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. li,)e �: ' �? ! j � t�e� � % Z,;Atlw <br /> Date: September 19, 2023 <br /> Print Name: Josie Gavieres <br /> Print Title: Director <br /> Signature. <br /> Telephone: 562-235-8835 <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 /> l: Risk Mgmt�lnsurance Requirements�WC Declaration 08152019 <br />