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^^N,r,~04i 2009 13:34 Fr. ii 3232665017 <br />^~. <br />~ ~ CERThtOLDER COPY <br />STATE P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 <br />COMPENSATION <br />INS6JRANC^ <br />FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />15SUE DATE: 02-09-2008 GROUP: <br /> POLICY NUMBER: 14p888H-2p0a <br /> CERTIFICATE ID: 31 <br /> CpiTIF1CATE EXPBiE6: 10-OS-2008 <br /> 10-01-9008/10-Oi-9000 <br />CITY OF BANTA ANA <br />290 S DAISY AYE <br />SANTA ANA CA 8870.1-0836 <br />This u tv terrify that we have iswed a valid Workers' Compensation Insurance policy In a form approved by tM <br />Cafifvrnla Insurance Commisolvner tc the employes named below for the pollcY period indicated. <br />TDIe poIICY le not subject to cancellation 41' the Fund except upon 30 days atlvtnve wrihen notice to the employer. <br />Wa will else glue you 30 dsys advance notice should Nis poky ba cance8ed prior to its normal explradon <br />This eerttfleste v} insuranea is nut an insurance policy rrd does not emend, estsnd or alter Ne eOVeraBe afforded <br />by iM OolicY listed Mrein NObnlNSmnding ~y requirement term or condlNOn v1 any contact w otMr davumen[ <br />with raspae to which rfila certl}ICate of naurm,ce may De Issued a tv which ii mry pertain tM Insurance <br />afforded by the pellvy deeer,'Ded Mrain is'subject to all dre terms, excWeirrns, end cvrxlRlona, of such Polley. <br />ORIZED REPRESENTATI PRESfD <br />ENPLOYER'S LIABILITY LIMIT INCLUDLN6 DLFlNSE COSTS: 51,000,000 PER OCCURRENCE, <br />Bt~ORSENEHY N1000 - NLCNAEL SWTAR PRES ~ EXCLUDED. <br />ENOORSENENT N1B00 -EDGAR PAZ VP, S,T -EXCLUDED. <br />ENOOASENENi N2086 ENTITLED CERTIFICATE fi0L0ERS' NOTICE EFFECTIVE 70-01-4000 LS <br />ATTACHED TO AND FORKS A PART OF THIS POLICY. <br />~~~~ <br />~~ <br />A`~ <br />v~v <br />yySL~ ¢ gay <br />Qy . ,,~,~ yJJ yon ` S9e`j <br />'/;( y ~ o <br />~rz ~f .qty ~ <br />' `/a.n~ <br />50 <br />OO1i001 <br />s0 <br />SO <br />;Ci <br />EM1H~LOYER <br />ARCHITECTS NOOONALD, $WTAR 8 PAZ INC. <br />3678 LONB BEACH BLVD <br />Lam. BEACH CA 90807 <br />sD <br /> <br />[JFU,CS] <br />Ie6~.a•0al PRINTED 02-08-2009 <br />