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<br />Oct 27 05 03:13p
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<br />Cit~ of Santa Ana PWA
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<br />714-847-5089
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<br />p.7
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<br />PQLlCYHOLDER COpy
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<br />STATE
<br />COMPENSATION
<br />INS V'A A tf'C.E
<br />FU~I:)
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<br />. P.O. BOX 8m, SAN FRANCISCO.CA 94142~O~7
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<br />CERTIFICATE OF: WORKIffiS'COMPENSAT16N INSURANCE
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<br />:cr~y,OF.~AhA ANA NA.
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<br />20 C I V I tCENTER PLA~A~.H6~s"..ANNEX
<br />SANTA ANA CA 92]01 .
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<br />GROUP:
<br />POLICY NUMBER: 1594126-2005
<br />CERTIFICATE 10: 104
<br />CERT,IFICATEfXPIRES: 01-01-2006
<br />. 01-01-2005/01-01-2006
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<br />JOB:'.JOB 2422; SAPS
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<br />iSSUE DAlE: 01-01-2005
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<br />This is to certify that we have issued a vaUd Work..rs' Compensation insurance poliCY In a form approved by the
<br />California lnsuril'l,ce Commissioner to the employer. named 'celow for the policy period indicated.
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<br />This policy is not subj~ct to cancellation by the Fund except upon '3O"days' advince writ~en notice to the employer.
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<br />We will also give you ,,~O~rliliyS"'ad.""9l1ce notice should this peliey be c.sncelled prior to Hs normal~xP,iratior~
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<br />This. cer~ifrcate ctf i~surarit:l!! is not ~n in,su~~nce policy and does not an;'ena. ex~nd-'~or' alter the .coverage at.forded
<br />by the, PC!~iC1.. ',,as Jistiild hereh''"'Ndtv\(Jtf'istan~ing. any feCi.... Ui.rem6.. nt. term. or condltion' ..O,f any contract, or-' other_.' dQ.' cument
<br />with respB~FJd \lVllich this certificate oft in"$urange' m~y"be"i.5sued or mlY 'per~ain..the insurance afforded .by the "
<br />PQli~ie~ deS:fribed herein is subject to i1:~,1 ~e' tern:f' excl~sr~,nsand conditi~ns of $uch policies. ;.'
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<br />AU1HORIZEEl REPRES5NT A TIV5
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<br />PRESIOEt'l
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<br />. EMP~OYER'S (LIAllt.Ily' LIMI.T INCLUOINll DEFENSE CO~TS: Scl.doo\oO~,OO ~ER ;OCC;U~.RENCE,
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<br />ENDD,RSEI4EN1'lI'20BE' ENTITLED CERTIFICATE HOI.DERS' iloTICEEFFEClivE 01-01-2005 ,IS AllACtlElITO ANlI
<br />FORMS A PART O.F lHIS P~I.I!CY.
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<br />APPROVED AS TO hj,..
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<br />A~qf;iVE(l
<br />n f.:'rEMhovgR.O~
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<br />Laura ,Still Sb"" 9
<br />Assislant eit)' Al',b'w","
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<br />LEGAl. NAME
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<br />(,;C)P, P()i'.il&WIL.1..!AM~
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<br />GOROON &101 ILL I ~MS GENERAL
<br />CONTRACTORS, INC.
<br />2 FARADAY
<br />IRVINE CA 92618.
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<br />'GW G C, INC.
<br />
<br />. 12/17 f2004
<br />JREV.3.03) PRINTED:
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<br />P0410
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