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CITY OF SANTA ANA <br />- PROJECT NO. 11-7509 CITYWIDE RESIDENTIAL STREET. REPAIR -PHASE 15 <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 fiunish the City of Santa Ana with an insurance certificate from my workers' <br />compensation insurance carrier certifying that i carry such ins»?T+ce 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_ <br />Signed <br />Title <br />Firm A l1 Annty'i c+?v? A s ?]?y?l-{- <br />Date lC,o 1?.,? ?? ? / a 1 ?c? A. ?/ <br />TO BE INCLUDED IN BID- PACKAGE <br />BP 9 of 29