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<br />'. <br /> <br />-..-', <br /> <br />SP <br /> <br />ISSUE DATE: <br /> <br />: :t.~t:>':", ',' '.c;EATHåLOERCOPY <br />. .: ,- "',. .." .::~:,.... ;'.~':.. _.~.. "::-<"}, "f '-~..~ <br /> <br />~O; :dO)(,'~~7, S~~:Jr~I$CO,CA\94,142-jQ@1 "~"< ' , <br /> <br />" "',::";¡:"..." "\'.>';;i':~<: .-' <br /> <br />CER~~~,!~~~~~: ,~~eRS'.:C9MPENS"TI~.~'/INàURANCE <br /> <br />.! . ~:;¡:'-):': ;;.::<~. .., <br />03-01-2OQ4 '. <br /> <br /> <br />-:-';' <br /> <br />.----^ ' <br />~," ',';ÎIfPI,"'" , :' <br />'. ,gl:Ä.E" <br />>:dOM"'Ñ;5~"t.Ö" <br />ULS U'Pt A.,Hc;.,. <br />~UN'D <br /> <br />. ",'", <br /> <br />:', .Io~.'t <br /> <br /> <br /> <br />. "," . .¡ <br /> <br />TWf\~lTyj)F;' SÅNrA' ANA <br />2.ó"t;)VtC~CEN-T~R; ÞLAZ~ ' <br />SANTA"'ÄtJ'A CA92101"}::'; <br /> <br />Sf <br /> <br /> <br />GROUP: <br />POliCY NUMBER: " , 14881143-2004 <br />CERTIF~i~\Q! ".14.. <br />CERTtFICATE>~IÆ&",,<!:2-9~ -2005 <br />. :' i' 03.oo1;729~~~01'-'~'<'j . <br />JOI;'A$IIÌST,ÞS ccNsûiit¡N¡;:.,:;,.' <br />':.". SER~Iè,1!S, :":' <br />N--Àoo.;J...;.i),,,, : <br />JJ - ~DD"- ':'o'tø '~l <br /> <br /> <br /> <br />.;"" <br /> <br />" <br /> <br /> <br />, , <br /> <br /> <br />., <br /> <br />This is to,C.rtl1y that we hive issued a valìd Workers' CornpenSltion insur...ce policy, in I form approved by the <br />C.lifot~"'¡~.lnce Commissioner to the employer l\iIImed below for tt\&,'P~~ period indic8ted. ' . <br />:~ ../~.'-'... ";~., ":::)'-':'~:'i.._~ . ",.. . <br /> <br />This policy is not subject to c.,cella'tion by tne Fundr'exc8Pt. upon 30 c ¡¡ys' 8dv~e '~n04:~to the employet. <br />.' :::"~,, " <br />':.,. .,:'. <br /> <br />We will 1150 giV8.YOLl"39^<1ayS",~~. notice shouldthi,s p ) lcy be cancelled prior to:its,notm8t~~XPìratiOn. <br /> <br /> <br />This C8fti~icat8{.)f:Ji~~:,J$ P.åt~ ins~.nc. policy and does not .n;1e~, e~terJd or alter theøoveraQ~ afforded <br />by the p~l¡çie$"~ hed~irt<-NqtwithsU!hdf/1g ,.any' re(juirement, term. or Ò-9n~itiQn Of .,V contr8Ctor;oth8l" document <br />with res~ctto:.t¥VhiChthls"c.t'tifi~. ~f.t~.!itë'~Y'b, issued or ma)!, pë~tàini the ¡nsut.,ce8fforde~ bV the:' . <br />Pá{icíes dtlscrìl:>8d herein is subject töáll;,"8~rTS;d.x~h;¡.!onS and condî~ions,ôt such policies. ' " <br />. ... <br /> <br />~. <br /> <br /> <br />AUTHÒRIZ:!b.,~~~~e~èNTATIVe PRES IDeI'if. ". ' <br /> <br />.~,. .>..~: f .~;: :~. ".".-"';;f ~.+ ,"*~..........,~ :;' .~~. . . . ~. \ ;;,. <br />", EMPU)m'$ LIAB.i.U'V .IIIIT INCLUDINCiI DEFENSE COST5:$1.'OdQ'~~1'ooiEJt Occu,uENCE. . <br />"p':" )" ""',;' ,. ... -;.,., -.' .,. ;~ < "- - -' -, -';;-, ~:::' " "": ').' ...":.:..:--,...-" ..:. ~. .'" <br />"ENQØRSEMQ.aT'#208IS' ENTITLEO CERTIFICATE '~tRS"\NónCt EFFEè'rnE'oa";01"S&<)04 XSATFAQtED. TO AND <br />'FOPMS A PART OF THI S ~OUCY¡ it ." ,.,,'\" ,'. ' " "0 ,', ' , "~~' ;,;, ", <br /> <br />",'õ""'.""'. <br /> <br /> <br />J!~ l!, ~ <br /> <br /> <br />" "',,;' <br /> <br /> <br /> <br /> <br />- -.'- <br /> <br />1> . . <br />,. })}." :1...,'(. ';~',. ,.,:f>, :r,:.' <br />,,'. I ~ },'" .', ,; , .~-:..l..,.- :'~'" <br /> <br />'~f(~' ; "~Ji:.~._-;'~: <br /> <br /> <br /> <br />-/~~_. <br /> <br />: ,~t':.l,,,,~:...,"'~l~!~<:.:(.'(,.4..: ,:.y . :. <br />i'... "" ,,', ¡,;hl" :\t~ ~,Wf:;;' ( ,{" " \. <br /> <br />, <br /> <br /> <br />t~~"/f~~.'<:~;'t ", "-' ,'. <br />':.tk "'," EMPLOYER <br />. '. ' ~:~<.~ :.'-;',.,,;' ....~:~.::.,:, ,- ...', <br /> <br />:' ,," <br /> <br />~GAL tWta <br /> <br />, :~,:.:.'~'~, ,;::;o;o;","!~''':''''''~ ",'. .. -' <br /> <br /> <br />c'o< t..;.;,,:,:;,:'? '¡"~ .f;1:~ <br /> <br />1~~'4~~~~~lf~'¥~;.~~f!..t~io""" <br />TUSTt N CA 9t78dk;~:<: ".; '.'.' <br />, "" ",' .¡ ." :0;:, :::"'. ~~ :": <br />;"-> "e:;< <br />.:'. .r~r(.'. <br /> <br />'¡ " <br /> <br /> <br />~ !: <br />.:.: ,,/., ~ ~ ':~::. " '. <br />'~'-~1:~i(f <br /> <br /> <br />;:'~':'.~".'.~:,,- ...~. ...' <br />,;,,, ,,' "'02'117/2004 <br />PRINTED: . ...J:.040~, <br /> <br /> <br /> <br />..-'::~l: . , <br /> <br />'~, <br />I <br /> <br />_V.:i-031 <br /> <br />.. <br />