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• • <br />CITY OF SANTA ANA <br />RESIDENTIAL STREET REPAIR <br />RECONSTRUCTION -PHASE 12 <br />PROJECT NO. 106718 <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 <br />the 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 <br />under California Labor Code Section 3300, unless the hired employee(s) is (are) persons excluded by <br />said Labor Code, I shall furnish the City of Santa Ana with an insurance certificate from my workers' <br />compensation insurance carrier certifying that I carry such insurance and that the policy shall not be <br />canceled nor the coverage reduced except upon thirty (30) days prior written notice to the City of Santa <br />Ana. /~//ice ~/ /_ f <br />Signed ~/ 1~L~~ ~~~~.•~~~ _ <br />`./K4bc~v+ 3r~l~~l <br />Title ~(j G~ Qr~° 5 i dFi/t-I- ,! <br />Firm A11 AwtFl~i ran ~A-~~1~1~ l~ <br />Date ~~°GPrytb~v I S,~,Lc1.C`L~i <br />• <br />TO BE INCLUDED IN BID PACKAGE <br />BP9ofl4 <br />