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AORKFIRS'COMPENSATION DECLARATION <br />I —.Nancy Ncala hereby affirm under penalty ot`perjury, the <br />(Namel'ifle) <br />Following declaration: <br />I certify on behalf of Nancy Alcala that during the term of my <br />(Consuftant, Company Name) <br />contract for , 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 />DA FE: <br />By'," <br />Name: (7 Ct <br />Title: Recreation Class Instructor <br />l, . <br />Telephone: ( - e) -, (I <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL, SUBJECT AN EMPLOYER 1-0 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 SEC'FION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. <br />P <br />