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WORKERS' COMPENSATION DECLARATION <br />1 ,. _ hereby affirm under penalty of perjury, the =e <br />(Namdrido <br />following declaration <br />I certify on behalf of —, --�)-ys F I c that during the term of my <br />(ConsullanWompany Name) <br />contract for Recreation Classes services with the City of Santa Ana, 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: ri > — ; — t j . <br />By <br />Name: J zc W s„ ,) n Z)t:Z- <br />Title: <br />Telephone: 75-0Z bC <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). N <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />N SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />