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Last Revised: 04/27/23 Page 38 Agreement <br />Sanitary Sewer Point Repairs 2022 and Project No. 2022.0120 <br />Wick Boulevard Vault Cover Replacement <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 <br />against liability for worker’s compensation or to undertake self-insurance in accordance with the provisions <br />of that code, and I will comply with such provisions before commencing the performance of the work of <br />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 />DocuSign Envelope ID: 6291E061-89C3-4EB6-92BE-BCDEBE7F0503 <br />510-577-3428 <br />City of San Leandro <br />Engineering Dept. <br />Kelly B. Clancy <br />July 14, 2023 | 9:45:38 AM PDT <br />835 E 14th Street <br />San Leandro, CA 94550