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WORKERS' COMPENSATION DECLAR T� ION <br />I Nancy Aleala hereby affirm Linder penalty of pe(jury, the <br />(Names l'itle) <br />following declaration: <br />I certify on behalf of Nancy Alcala that during the term of my <br />(Consuhant/Cumpany Name) <br />contract for Recreation Class services with the City of Santa Ana, I will <br />not employ any person in any manner so as to becotne 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: c)-) G <br />Name: i\Giy1Ct ri (C`aG—f _ <br />Title: Recreation Class Instructor <br />Telephone: f 710) 73 — <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). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE. LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />pd,�ar. <br />P <br />