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<br />Version: 17 April 2024 Page 40 Agreement <br />Rehabilitation Phase for Annual Street Paving 21-23 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 /> <br /> <br />Docusign Envelope ID: C04669A7-472C-4C9A-AB9B-0F9E0F652DBC <br />94568 <br />Michael Gates <br />July 31, 2024 | 2:02:29 PM PDT <br />11555 Dublin Blvd <br />9258299220 <br />Dublin, CA