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Last Revised: 06/12/2024 Page 8 Agreement <br />Annual Street Overlay/Rehabilitation 2019-21 – Phase II Project No. 2020.0050 <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 /> <br /> <br />Docusign Envelope ID: 16550F75-C810-4903-888B-56C0BAEA8DF8 <br />DeSilva Gates Construction LLC <br />Michael Gates <br />Dublin, CA 94568 <br />925-829-9220 <br />July 19, 2024 | 4:22:58 PM PDT <br />11555 Dublin Blvd