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Last Revised 10/13/2025 Page 37 Agreement <br />Annual Sidewalk Repair Program 2024-25 Project No. 2025.0060 <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 />Docusign Envelope ID: 6841DE30-5CC9-4879-88E5-B2A73A87BD80 <br />94580 <br />16440 Ashland Ave San Lorenzo Ca <br />5109540739 <br />October 27, 2025 | 8:55:59 PM PDT