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CITY OF SANTA ANA <br />PROJECT NO. 1 16734: CHESTNUT AVE. FROM STANDARD AVE. TO ELK LN. <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 awaze of the provisions of Section 3700 of the Labor Code, which requires every employer to <br />be insured against liability for worker's compensation or to undertake self - insurance in accordance <br />with the provisions of the Code, and I will comply with such provisions before commencing the <br />performance of 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 <br />employer under California Labor Code Section 3300, unless the hired employees) is (are) persons <br />excluded by said Labor Code, I shall furnish the City of Santa Ana with an insurance certificate <br />fi-om my workers' compensation insurance carrier certifying that I carry such insurance and that the <br />policy shall not be canceled nor the coverage reduced except upon thirty (30) days prior written <br />notice to the City of Santa Ana. <br />Signed <br />Title � .� �, 5�a.�•��c <br />Firm '�� ��� �O� 4� SQ.`C �1 v '�@ Z`n� <br />Date ��«�c�`�sz`C `Z� �� 2��� <br />BP8of13 <br />