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WORKERS' COMPENSATION DECLARATION <br />Melina Herrera <br />(Maine/title) <br />following declaration <br />hereby affirm under penalty of perjury, the <br />I certify on behalf of — Melina Herrera — that during the term of my <br />contract for <br />(Consulwt'Company Name) <br />Recreation Class services with the City of Santa Aria, I will <br />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 those provisions and provide proof of workers' compensation coverage, <br />DATE: �/ <br />M <br />Name: 1A4217 <br />Telephone: <br />WARNING: FAILURE TO SECURE WORKERS'COMPENSArioN COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OFTHE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />