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<br />SP <br /> <br />CERTHOLDER COpy <br /> <br />STATE <br />COMf>"NSATION <br />INSUFIANCE <br />FUND <br /> <br />P.O. BOX 807, SAN FRANCISCO,CA 94142.o.'QaQ.7 <br /> <br />,4- iJJJo3- o14-4tp <br />A- ~3..0ft¡Þ- <br /> <br />CERTIFlCA TE OF WOftKERS' COI\IIPENSA TION'INSURAN'CE, <br /> <br />ISSUE DATE: <br /> <br />10-01-2003 <br /> <br />GROUP: <br />POLICY NUMBER: 1209851-2003 <br />CERTIFICATE 10; 22 <br />CERTIFICATE EXPIRES: 10-01-2004 <br />10-01',2003/10-01-2004 <br /> <br />JØB:c A,CL OPgRATIONS <br /> <br />ITY OF SANTA ANA <br />CONIUNITY DEVELOPMENT AGENCY 1'1-25 <br />P.O. 80X 1988 <br />SANTA ANA' <br />CALIFORÞlIA 92702- <br /> <br /> <br />This is to certify that we have issued a valid Workers' Compensation insurance policy in a fl;irm'j p¡¡ro1ied by the <br />California Insurance Commissioner to the employer named below for the policy period indicated. <br /> <br />This policy is not subject to cancellation by the Fund except upon 30 days' advance written notice to the employer. <br /> <br />We will also give you .30d"l-s' advah"e notice should this policy be cancelled prior to <br /> <br />normal expiration. <br /> <br />This certificate pf ihsUran"e is nc¡t an inst¡,.,ce poJìcy~d<>es not a~nd., extenct'oralter the cpverage afforded <br />, bY the policies listed herein. Nötvyithstanding any <equirement. term. or condi,ion' of any contract or other dc¡cument <br />with respect to which this "èrtificate of, inturan"", l'iji!Ybèissued or may perjafn. the insurarice afforded bY the <br />. poll"ies dèscribed herein is subject to all t~e te,m~. exclt¡siòns and conditions of such policies. <br /> <br />.~ <br /> <br />.A~c. <br /> <br />&£- <br /> <br />AUTHORIZED RËPRE'SENTATIVE <br /> <br />PRESIDENT <br /> <br />_LOYER'S LIABILITY LIMIT UIQLUC>INá.~"£N$f!.(:'.QST.S,.. $1.000..000.00 P~R,'Ocçu~RfNCE. <br /> <br />ENDORSEMENT' #2065 ENTITLED <br />FORMS A PART OF THIS POLICY. <br /> <br />HOLDERS' NOTICEEFFECTtWI0-(M-2003,.IS ATTACHED.TO AND <br /> <br /> <br />A <br /> <br /> <br /> <br />LEGAL NAME <br /> <br /> <br />THOMAS HOUSE <br />PO BOX 2737 <br />GAROEN GROVE <br /> <br /> <br />THOMAS HOUSE TEMPORARY SHELTER <br />(A'NåN:PROFÌTORGi ) <br /> <br />.. <br /> <br />. :' <br /> <br /> <br />.: , <br />, 08-17-2003 <br /> <br />