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Last Revised: 12/19/2022 Page 7 Agreement <br />Curb Ramp Upgrades for Paving 2021-23 Project No. 2022.0050 <br /> <br /> <br /> <br />WORKERS’ COMPENSATION INSURANCE CERTIFICATION <br /> <br /> <br />Pursuant to Section 7-4 of the Standard Specifications, the Contractor certifies as follows: <br /> <br /> <br />I am aware of the provisions of Section 3700 of the Labor Code which require every employer to be insured against <br />liability for worker’s compensation or to undertake self-insurance in accordance with the provisions of that code, and <br />I will comply with such provisions before commencing the performance of the work of this contract. <br /> <br /> <br />Signed: Date: <br /> <br /> <br /> (Typed or Printed Name) <br /> <br /> <br /> <br />Business Address (Street Address, City, State & Zip Code): <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />Business Phone: ( ) <br /> <br /> <br /> <br /> <br /> <br />DocuSign Envelope ID: E12D6D7A-A27A-49D6-8154-B5C52171768A <br />San Leandro, CA 94577 <br />. <br />Kelly B. Clancy <br />510-577-3366 <br />835 East 14th Street <br />February 16, 2023 | 2:47:11 PM PST