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<br />Last Revised: 9/27/2024 Page 35 Agreement <br />San Leandro Marina Buildings Demolition Project No. 2020.3080 <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 <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: F39BCB22-A9ED-46C1-A7DD-DE1C30BEB37E <br />Valentin Pena <br />3412088855 <br />September 30, 2024 | 12:14:23 PM PDT <br />San Lorenzo, CA 94580 <br />1791 Via Hermana