ALL AMERICAN ASPHALT (MID-CITY NEIGHBORHOOD IMPROVEMENT (WEST OF BRISTOL))

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CITY OF SANTA ANA • Project No. 10-7554 Mid-City Neighborhood Improvement (west of Bristol St.) Project No. 07-7577 Edinger Ave. Improvement from Mohawk St. to 400' e/o Mohawk St. PROPOSAL AND CONTRACT AGREEMENT WORKERS' COMPENSATION INSURANCE CERTIFICATION As required by California Labor Code Section 1860 and 1861, the Contractor certifies as follows: I am aware of the provisions of Section 3700 of the Labor Code, which requires every employer to be insured against liability for worker's compensation or to undertake self-insurance in accordance with the provisions of the Code, and I will comply with such provisions before commencing the performance of the work of this contract. If I, as the Contractor, now or at any time during the course of this agreement, qualify as an employer under California Labor Code Section 3300, unless the hired employee(s) is (are) persons excluded by said Labor Code, I shall furnish the City of Santa Ana with an insurance certificate from my workers' compensation insurance carrier certifying that I carry such insurance and that the policy shall not be canceled nor the coverage reduced except upon thirty (30) days prior written notice to the City of Santa Ana. Signed ~~z~ ~~~ t--=-rC ~~. • _ 1/ n Title ~~ ~ ., I/ ( 1' i~j~,Qf~/~J~"' ~~0° , Firm ~-(it ~ ~_('~'-1-~ f'7"~ P Date ~Q.I~ ~ ~, ~-a ~ O • TO BE INCLUDED IN BID PACKAGE BP 10 of 31