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• CITY OF SANTA ANA <br />PROJECT N0.08-5018: TRAFFIC SIGNAL INSTALLATION ON HAZARD AVE & ROSITA ST <br />• PROJECT N0.08-5019: TRAFFIC SIGNAL INSTALLATION ON HAZARD AVE E/O GATES ST <br />PROJECT NO. 08-5020: TRAFFIC SIGNAL MODIFICATION ON MCFADDEN AV & NEWHOPE AV <br />PROPOSAL AND CONTRACT AGREEMENT <br />WORKERS' COMPENSATION INSURANCE CERTIFICATION <br />As required by California Labor Code Section 1860 and 1861, the Contractor certifies as follows: <br />I am aware of the provisions of Section 3700 of the Labor Code, which requires every employer to be <br />insured against liability for worker's compensation or to undertake self-insurance in accordance with the <br />provisions of the Code, and I will comply with such provisions before commencing the performance of the <br />work of this contract. <br />If I, as the Contractor, now or at any time during the course of this agreement, qualify as an employer under <br />California Labor Code Section 3300, unless the hired employee(s) is (are) persons excluded by said Labor <br />Code, I shall furnish the City of Santa Ana with an insurance certificate from my workers' compensation <br />insurance carrier certifying that I su h incur a and that the policy shall not be canceled nor the <br />coverage reduced except upo arty riot ritten notice to the City of Santa Ana. <br />,,°' '" <br />Signed <br />• Timithy <br />Title <br />,Firm ' ~ -~ D 10 <br />Date ~'~~'~~ <br />• <br />TO BE INCLUDED IN BID PACKAGE <br />BP 10 of 32 <br />