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J A SALg1AR OONBTRUOTION & BU PPLY CORP <br />BfaN.HPABORBLVD. <br />tANgBPACA 80891 <br />CITY OF SANTA ANA <br />PRO]ECT N0.10-6404, DIAMOND PARK MUTUAL WATER COMPANY WATER MAIN <br />IMPROVEMENTS (REBID) <br />PROLANDCONTRACTAGREEMENT <br />WORKERS' COMPENSATION INSURANCE CERTIFICATIO <br />As requird by Califamia Labor Code See[ioa 1860 end 1661, the ConVactor certifies ss foRov?: <br />are of the provisions of Section 3700 of the Labor Code, which requves every employerto <br />be wured ageins(hsbhity for worker's oomperdsalion or fo wderlake selfiasmwce io accorclauoe <br />with the provisions of the Code, and 1 will comply with such provisions before commencing the <br />performance of the work of tltis conpact <br />If I, as ?e ConVaefor, now or at any time during the course of AE agreement, gwlify as an <br />wnployer wilder California Labor Cade Section 3300, unless iM hid employeds) is (are) persona <br />excludd by said Labor Code,1 shall furnish the Gry of Sand Ana with w iuswwce ceNfiwte <br />Gommywarkers'mmpensalionin wcecarnercertifyingihallcwysuchinsurancewdthallhe <br />policy shaft not be cwceld nor cavemge rdwed except upon thhty (30) days prior wnneu <br />noticeto?eCityofSwtaAna? <br /> <br />lama, <br />Sigrid <br />Title <br />Firm <br />Date <br />TO BE INCLUDED M BID PACKAGE <br />BP90F 14