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TO: City of Santa Ana <br />ATTN: City Clerk and Risk Manager <br />SUBJECT: Sole Proprietor /Partnership /Closely Held Corporation with No Employees <br />Please let this memorandum notify the City of Santa Ana that I am a <br />0 sole proprietor <br />❑ partnership <br />❑ closely held corporation <br />and do not have any employees whose employment requires me to carry workers' <br />compensation insurance. Therefore, I do not carry workers' compensation insurance <br />coverage. I further warrant that I understand the requirements of Section 3700, et seq., <br />of the California Labor Code with respect to providing Workers' Compensation coverage <br />for any employees. I agree to comply with the code requirements and all other <br />applicable laws and regulations regarding workers' compensation, payroll taxes, FICA <br />and tax withholding and similar employment issues. I further agree to hold the City of <br />Santa Ana harmless from loss or liability which may arise from the failure to comply with <br />any such laws or regulations. <br />Contractor Signature <br />Charlotte D. Whitney <br />Printed Name of Contractor <br />June 24, 2014 <br />Date <br />'J <br />--�-1 `f <br />Risk Management Approval: <br />Date <br />