Sole Proprietor 2023 Caha, BeckyDeclaration of Sole Proprietor
DECLARATION AND ADDENDUM TO ALL CONTRACTS AWARDED TO
Becky Caha
Individual or Organization Name
I declare for the purpose of inducing the City of La Quinta to go forward with any contracts
awarded to Becky Caha as follows:
I am the authorized representative of Becky Caha
an independent contractor for the purposes of the California Workers' Compensation and Labor
laws. This organization will hire no employees other than the parents, spouses, or children of its
board members for work required for any bid or contract awarded to
Becky Caha . All worked required will be
performed personally and solely by me, other board members of the organization, their parents,
spouses or children, or persons who perform voluntary service without pay to the organization.
If, however, the organization shall ever hire employees to perform this contract or any portion
thereof, the organization shall obtain Workers' Compensation Insurance and provide proof of
Workers' Compensation Insurance coverage to the City of La Quinta. If the organization shall
ever hire a subcontractor to perform this contract or any portion thereof, and the subcontractor
has employees, then the organization shall require its subcontractor to obtain Workers'
Compensation Insurance Coverage, or the organization shall obtain Workers' Compensation
Coverage for that subcontractor's employees.
This document constitutes a declaration by the organization against its financial interest, relative
to any claims it should assert under the California Workers' Compensation and/or Labor laws
against City of La Quinta relating to any bid or contract awarded to
Becky Caha
The organization will defend, indemnify and hold harmless the City of La Quinta from any and
all claims and liability, including Workers' Compensation claims and liability that may be
asserted or established by any party in the event the organization hires an employee in violation
of this addendum, and the organization will further indemnify the City of La Quinta for all
damages the City of La Quinta thereby suffers.
I agree that these declarations shall constitute an addendum to any bid or contracts awarded to
July 6, 2023
Date
Authorized R presentative
Declaration Regarding California Workers' Compensation
You are required to complete this form because you have not filed a certificate regarding workers'
compensation insurance with City of La Quinta. California law requires all employers to carry workers'
compensation insurance, even if they have only one employee. If you do not know whether you are
required to carry workers' compensation insurance, find out by contacting the California Department of
Industrial Relations ("DIR"). Information is also available on the DIR's website at http://www.dir.ca.gov.
You should also consult with your attorney, insurance agent or broker, or carrier regarding the specifics
of your situation and your options. If you are subject to the Workers' Compensation Laws of California,
you must promptly file a certificate of Workers' Compensation Insurance with City of La Quinta. If you
have a certificate of self-insurance from the DIR, you must file that certificate with City of La Quinta.
When completing this form, remember that the term "employee" includes clerical persons as well as any
other persons employed by your company including drivers.
ACKNOWLEDGMENT
BC (initial) California Labor Code § 3700 requires employers to carry workers' compensation
insurance or to obtain a certificate from the Director of Industrial Relations demonstrating that the
employer is self -insured. California Labor Code § 3700.5 makes it a criminal offense for an employer to
fail to secure compensation as required by the workers' compensation provisions of the Labor Code.
Violation of Labor Code § 3700 is punishable by a fine of up to $10,000 and/or imprisonment for up to
one year.
BC (initial) California Labor Code § 3710.1 provides that where an employer fails to provide
compensation required under § 3700, the Director of the Department of Industrial Relations shall issue a
stop order, prohibiting the employer from using employee labor until such time as the employer
complies with the provisions of § 3700. Labor Code § 3710.2 makes it a criminal offense to disregard
such stop orders.
BC (initial) I acknowledge that if evidence is found that contradicts this declaration, City of La Quinta
will promptly notify all relevant state agencies to ensure full insurance compliance required by Workers'
Compensation Laws of California.
BC (initial) 1 understand that California Labor Code § 3700 et seq. requires employers to provide
workers' compensation insurance coverage for any employees of my business. I hereby warrant that this
business is exempt from the California Labor Code provisions regarding workers' compensation
insurance because it has no employees.
BC (initial) I agree to hold City of La Quinta and its officers, officials, employees, and agents harmless
for loss or liability which may arise from the failure of my business to comply with the laws of the State
of California regarding workers' compensation insurance.
BC (initial) If I hire employees in the future, I will immediately notify City of La Quinta and provide a
certified Workers' Compensation certificate to the City.
CERTIFICATION
I (we) certify under penalty of perjury, under the laws of the State of California, that I (we) have read
and understood the above stated requirements regarding Workers' Compensation and that I(we) am
(are) in compliance. I(we) certify that the forgoing is true and correct.
Executed this 6 `h day of J u ly 2023 at Huntington Beach , California
Signature of D larant
Becky Caha
Print Name of Declarant
N/A
Print Name of Company