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Contractor Information <br />LMOBi tlrMarro <br />CA UFORNLA OA MAK RENTALS. INC <br />&ft <br />Com"ion <br />Stawn <br />Ad7ve <br />Rtg!Vtr@OW NuNAM <br />ICKOD17497 <br />R@Skmdw date <br />71312021 <br />RF94trlroon • "union daft <br />6f3017on <br />Milling Address <br />15SO E. SU YT CEMMUDE PLACE rSJWA ANA 92705 CA Lmk._ <br />PL"C*I AGdr*" <br />2550 E. SA I T GER1RUDE PLACE SANTA ANA 92705 CA UWL.. <br />Emrll Addn <br />Trbft N0nWf?P5A <br />C+LLTFORHLA BARRICAUr- INC. <br />Lilum* Numb*rlsj <br />M21 857'33 <br />C$L13:785733 <br />Legal Entity Information <br />corpmpratlQR NumB*r: <br />C203S262 <br />Federal Eanployrnent IdantlAcatkm Numbar- <br />Pnt wmm Name - <br />MARK HURL 7 <br />Vice Pmsldam N4nw: <br />KELL LE HuRST <br />Treasurer Name: <br />KELLIE HURST <br />Secretary Name, <br />K F I L I E HuRST <br />CEO Nw": <br />KELLTE HURST <br />Agent of Service Fame; <br />NANCY DOWD <br />A#*M of 5#rykv M iling Addrow <br />9921 C RMa MOUNTAIN ROAD 01. 382 SAN DTEC.092129CA UnimiStates of Ar mnica <br />Workers Compensation <br />Do you lease employees No <br />through Professional Ernploy*r <br />Organization (PEp)7: <br />Please provide your current <br />workers compensation <br />insurance information below: <br />PEO PEO PEO <br />PEO ln#urmationNarne Phone Email <br />Insured by Carrier <br />Registration History <br />Effective Date 6tpirvtkm Ogee <br />611212018 6130(2019 <br />W912017 6f3012018 <br />611512016 6130J2017 <br />9123f2f015 <br />613012016 <br />313112015 <br />6f301201S <br />71V2019 <br />613012M <br />71112020 <br />fib IM21 <br />71V2021 613012022 <br />Policy Holder Neme:CALIFORNIA BARRICADE RENTALS, INC.Insurance Carrkw. <br />STATE COMPENSATION INSURANCE FUN DPolicy NumbeOX360820Inoeption date:613012020Expiraftn Date: <br />5f29f2021 <br />City Council 13 — 104 2/1/2022 <br />