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EXHIBIT "A" <br /> WORKERS' COMPENSATION INSURANCE CERTIFICATION <br /> Every employer, except the State, shall secure the payment of compensation in one or more of the <br /> following ways <br /> (a) By being insured against liability to pay compensation by one or more insurers duly <br /> authorized to write compensation insurance in this State <br /> (b) By securing from the Director of Industrial Relations, a certificate of consent to <br /> self-insure either as an individual employer, or as one employer in a group of <br /> employers, which may be given upon furnishing proof satisfactory to the Director <br /> of Industrial Relations of ability to self-insure and to pay any compensation that <br /> may become due to his or her employees <br /> CHECK ONE <br /> I am aware of the provisions of Section 3700 of the Labor Code which requires every <br /> employer to be insured against liability for Workers' Compensation or to undertake self-insurance <br /> in accordance with the provisions of that Code, and I will comply with such provisions before <br /> commencing the performance of the work and activities required or permitted under this <br /> Agreement (Labor Code §186 1) <br /> I affirm that at all tines, in performing the work and activities required or pennitted under <br /> XiisAUeement, <br /> I shall not employ any person in any manner such that I become subject to the <br /> workers' compensation laws of California However,at any time, if I employ any person such that <br /> I become subject to the workers' compensation laws of California,immediately I shall provide the <br /> City with a certificate of consent to self-insure, o; a certification of workers compensation <br /> insurance <br /> I certify under penalty of penury under the laws of the State of California that the information and <br /> representations made in this certificate are true and correct ] <br /> Sons of Norway Date l Z f GI/l <br /> By-0'04,44'Aaed,- <br /> Melanie Hendrickson <br /> 5 <br /> 1 teadj m,AgreemenFs\Sons ofNorwav Ficdit}Use Agreement.doex <br />