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CERTHOLDER COPY ' <br />�S ATE P.O. BOX 81j7MPIENSATION, SAN FRANCI$PQ,GA; 94142-0607 '�t�03 11t ` ' <br />INSURAN7C <br />3 <br />FUND CWIFYCATE OF WORKERS' COMP1NSATf6N IMLIR'ANCE <br />,., <br />ISSUE DATE: 110-017200;3GROUP: <br />,POOCY NUMBER: f7173i0-266i' <br />CERTIFICATE ID; , 15 <br />CERTIFICATE, P.,XPIRE^,x. 7Jjp1-2790; .�•' <br />„ . <br />/16-414064 <br />CITY OF SANTA ANA SP,s. <br />COMIADNITY., DEWELOMENT AGENCY M-25 <br />PO BOX 1988 <br />SANTA ANAh,A 92702 <br />y r.� <br />This is to certify that we have issued a valid Workers' Compensation insurance policy :in a form ;aPfxovQd by the <br />California:;14urar p Commissioner to the empldYer named below for the polic , erioo <br />X p died �,: v <br />This policy is not ,subject to cancellation by the 'Fund except upon 10 days' advance, written notroe. to the employer. <br />We will also give you 10 days" advance notice slroutdrthjs� policy be cancelled prior to-:-ijs normal axprration. 4,.. <br />This certificate of insurance is not an instiraoce:policy ,and does not amend, extend or alter, the goyerage Afforded <br />x by;,tPte polieles fist l hereiir, NOLtalthstanding any requirie;int, term, or condition of any ibohtraet oeo� tt99r docurncn <br />with respect to which this certificate of insurance may bra issuad,or rrisy pertain, the insurance afforded by the <br />policies described herein is subject to aft the tbrms;~� xclus➢ons'and conditions of such policies. <br />�t <br />6 <br />AUTFtQRIZEO REPf,#SEIyfiATIVE PRESIDENT ' <br />' F9PLOYJI�.?'S LIABILITY LIMIT Ik LUOIM4 Mb NSE COSTS: A1,000,000.00 PfR OCCURRENCE. . <br />tx yyy��ku <br />S 3' • 4 it ..f /t �l`l tl° l}�'�f t tY +o vt 4,• din. <br />s� l.i �4f <br />sz s <br />y ns 4 f{.rx a- <br />lil' r.{ d$. ,•'a 41 'h <br />I?eOply JC Auorncv • <br />A ' <br />s z, q,w. ` 5 , t• , ' v , <br />Vq�y}..����..JJ��•y{._, kt., ^{'ir.4,v '..i'� <br />,`^ <br />4 'i. W4TH St . .. 'ate' '� `00FNICIL ON A�IIt*_ y.'Y�+;Yx '" 5r• <br />141 StQO <br />E <br />4 4 <br />d r" ie all s <br />3003 4 ,. nnw.r2.nr. , OD-17 -_., <br />