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CITY OF SANTA ANA <br />Project No. 13 -6796: Chestnut Avenue Class lI Bikeway from Standard Avenue to <br />Grand Avenue; CM- 5063(148) <br />Project 14 -6813: Alley Improvement -FY 13/14 <br />Project No, 14 -6803: Chestnut Avenue Rehabilitation from Broadway to Main Street <br />PROPOSAL AND CONTRACT AGREEMENT <br />WORKERS' COMPENSATION 1NSURANCF CFRTIFICATION <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, unloss the hired employee(s) is (are) persons excluded by <br />said Labor Code, I shall furnish the City of Santa Ana with an insurance certificate from my workers' <br />compensation insurance carrier certifying that I carry such insurance 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 />Signec <br />Title <br />Firm /411 t ee 1ert= 4 � P t <br />Date Sid N <br />TO BE INCLUDED IN BID PACKAGE <br />BP 10 of 27 <br />23A -17 <br />