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CITY OF SANTA ANA <br />PRWECT09- 003S:17rnSTREETTRIANGLE <br />PROPOSAL AND CONTRACT AGREEMENT <br />WORKERS' COMPENSATION INSURANCE CERTIFICATION <br />As required by California tabor Code Section 1860 and 1861, Ihe COnIfaGOr certifies as follows: <br />I am aware of Ihe provisions of Section 3100 0[ Ihe Labor Curie, which requirrs every employer to be <br />insur¢d against liability for worker's eompense[ion ur to underlakeself- insurance in aceordance with she <br />provisions of the Code, and 1 will comply wish such provisions before commencing Ihe performanceof <br />the work of lMs comraci. <br />If I, as the Contractor, now or al any lime during Ifie coarse of This agrcemenl, qualify as an employer <br />undo California Labor Cade Section 3300, unlesslhe hired employees) is (are) persons eaclod¢d by <br />said labor Code, I shall famish the Gty of Santa Ana with an insurance cerOGcale from my workers' <br />compensation insurance artier certifying Ihal I Barry such insurance and that the policy shall oat b¢ <br />canceled nor the rauerdge reAuced except pan lhidy (30) days poor written notice to the Cily of Santa <br />Ana, <br />Signed SHAYAN SHADROU <br />Tide President <br />Corm GREENIRND CONSTRUCTION INC. <br />Dace Oefober 19.2011 <br />BPBofl3 <br />