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WORD; ERS" Q'014,IPENSATION DECLARATION <br />I jose Romo hereby affirm under penalty of perjury, the <br />(tie) <br />follov,,in,p, declaration: <br />I certify on behalf of --- Jose Romo that during the term of my <br />(Cons u Rant/Company Name) <br />contract for Fiestas Patrias 2017 services with the City of Santa Aria, I will riot employ <br />any person in any manner so as to become subject to the workers' compensation laws of <br />Califcii.riia, and agree that if I should become subject to the workers' compensation <br />provisions of Section 3700 of the Labor Code, I shall forthwith comply with those <br />provisions and provide proof of workers' compensation coverage. <br />DATE: -,September 1, 2017 <br />By: <br />Name: Jose Romo <br />Title: Consultant <br />Telephone: (714) 612-9227 <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 />. \2k <br />