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CIFV OF SANTA ANA <br />PROIECTN0.10?6405 <br />WORKERS' COMPINSA180NMSVRANCErFRTIPICAIfON <br />Asrequired byCaBfomiaLaborCodaSecfian 1860and 1661,theCongaclorcerdfies asfollows <br />PROPOSAL ANDCONTRACTAGRF,EMENT <br />I am aware of Aa provisions of Sacfien 3100 of the Labor Code, which requires every employer to <br />be irsm¢d again liability for worker's compensation or to undertake self-insurance in arcordartce <br />wig she proviaioim of tGe Carlo, and 1 Al wmply with such provisions hefaro Wmmenaing the <br />pe?ormance of fha work of tltiseonhad, <br />If I, as rho Contractor, now or at any Bme during Ibc course of dtis agrcementi qualify as an <br />employer under Califamia Labor Code Salion 33W, wdess the hhed employee(s) is (arc) ptcsoms <br />eaoluded by sad Labor Codq 1 shill fomlah the Ciry of Santa Ana wlfh ao inauraoce euvfirate <br />Rom mp wodcem' compensation insuaaca coma cerdfyu>g That I carry such ?stuanca and Bmtt? <br />policy shell not be amceled nor the aovemgereduced except upon Thirty (30) days prior wnnen <br />no6cetoduCitycfSanlaAna ` A <br />Signed /,? ? r <br />Tme Ste hen DorB?k /Vice President <br />Fig Stephen Doreek Equipment Rentals, Inc. <br />Qau I1?9?20?1 <br />TO BE INCLUDEQ M BID PACKAGE <br />BP 80F 17