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CITY OF SANTA ANA <br />Proj¢ctNo126152, 201 12012 OmnibusConcrele Replacement Contract <br /> <br />WORKERS' COMPENSATION INSURANCE CERTIFICATION <br />As required by California Labor Coda Section 1860 and 1861, the Contractor certifies as follows? <br />PROPOSAL AND CONTRACT AGREEMENT <br />I am aware of the provisions of Section 3700 of the Labor Code, which requires every employer b be <br />insur¢d against liahifily forworker's compenselion orto underfakeselGinsurancein accordance with the <br />provisions of fhe Code, and I will comply with such provisions before commencing the performance of <br />Iheworkofthiscontract. <br />If I, as the Conlraetor, now or al any time during the course of Ihis agreement, qualify as an employer <br />under California Labor Code Section 7700, unless the hired employee(s) is (are) persons excluded by <br />said LaborCode, I shall furnish theClty of Santa Ana with an insurance certificate from my workers' <br />compensation insurance carrier certifying Ihal I carry such insurance and Ihal fhe policy shall not be <br />canceled nor [he coverage reduced except upon thity (70) days prior wri[?n notice to [he Gly of Santa <br />Ana. <br />Signed ?,L <br />T(le ??{?. M??OD? ?iD3J r <br />Firm ??rJrJAJVI? (?y61nI?S Q?1VnJL?a1.5 C?. <br />Date ?? O?-"(D??1. 201\ <br />BP?9 of 14