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<br />Notice of Award 6/21/23 Page 9 Agreement <br />Surface Seal Phase for Paving 2021-23 Project No. 2022.0050 <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 />DocuSign Envelope ID: BF382849-3F16-4358-96E7-72CAC7F22144 <br />Tim Schmid <br />10240 San Sevaine Way <br />Pavement Coatings Co <br />916 <br />July 19, 2023 | 9:45:38 AM PDT <br />Jurupa Valley, CA 91752 <br />642-1751