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SP <br />�+.�.A CERTHOLDER COPY ' / <br />i7 �I"!'�TE P.O. BOX 807, SAN FRANCISCO,CA 94142- 0807' A'�(�3 -04-`i <br />COMPENSATION <br />INSURANCg <br />FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE J lfJi <br />ISSUE DATE: 10-01 -2003 GROUP: - <br />POLICY NUMBER: .1209851 -2003 <br />CERTIFICATE 10: ,..22 <br />CERTIFICATE EXPIRES: 10 -01 -2004 <br />10-01'-- 2003/10 -01 -2004 <br />CITY OF SANTA ANA SP JOB: ALL OPERATIONS <br />COMMUNITY DEVELOPMENT AGENCY M -25 <br />P.O. BOX -19$8 <br />SANTA ANA <br />CALIFORNIA 92702 -198$' <br />This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the <br />California fileurance Commissioner to the employer named below for the policy period indicated. <br />This policy is not subject to cancellation by the Fund except upon 30days'. advance written notice to the employer. <br />We will also give you,30 days" advance notice should this policy be cancelled prior to its normal expiratow. <br />This certificate of insurance is not an insurance policy and does not amend extend"or' alter the coverage afforded <br />by the policies listed herein. 'Notwithstanding any requirement, term, or condition of any contractor other document <br />with respect to which this certificate of insurance may be issued or may Pertain, . the insurance . afforded by the <br />policies described herein is subject to all the terms, exclusions and <br />conditions of such.: policies. ; <br />AUTHORIZED REPRESENTATNE PRESIDENT <br />`EMPLOYER'S LIABILITY LIMIT INCLUDI€*.:DEFENSP (79S ?S• -. $1,006-000.00 PER 'OCCURRENCE. <br />ENDORSEMENT #"ES ENTITLEED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 10-01-200$ IS ATTACHED TO AND <br />FORMS A...PART 01'` " -*;S POLICY, ,. <br />s�t"L3 AS TtiCDa`Li <br />tL. i';• <br />rx <br />g uai. <br />.::EMPLOYER <br />.M LEGAL NAME <br />d <br />F " THOMAS HOUSE TEMPORARY,,SHELTER <br />THOMAS ►aurE rEMPORAl3Y SHELTER <br />PO. BOX' 273`7' (A NONtiP1ZItFIT i :. . <br />GARRET GROVE CA 92842 ' <br />` • ��Ev.s•o31 _ „. aa`Htatttn 69- 17-2009 Orono..,' <br />