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<br />11/12/2~~4 <br /> <br />12:~9 <br /> <br />NO. 605 (t~~2 <br /> <br />: . <br /> <br />CERTHOLOER COPY <br /> <br />STATE P,O. BOX 4201$07, SAN FRANCISCO, CA 94142-0SQ7 <br />C:OMJI'I:N~TION <br />I,",SU""Ne. <br /> <br />FUN D CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> <br />ISSUE DATS: 11-12-2004 <br /> <br />MOup: <br />POLICY NUMBER: 1515671-200i <br />CERTIFICATE ID: 15 <br />CERTIFICATE EXPIRES: 04.01.~005 <br />o,-o~-'oD'lo'-o~-'OD5 <br /> <br />CI:r1' Of SJlJI1'A AHA <br />PUMoIC IIOEOOl 1I.GllZlCl" 1f-36 <br />PO BOX 1~88 <br />BAlITA J\DIA CA U702 <br /> <br />JOIi ~ A~'m': JOB PAKCQ <br /> <br />I <br /> <br />This is to ..rII"'II'4IWlI ~1I'" 1N~t\l. valid WorI<er, Compllnllllion inCuran09 polit;y in a form llPomed bytl1e Califomill <br />InllUJ'M<e Comm"'-'Ionllr to Ill, ..,.p1OYllr namG<! ~Iow for lh9 polit;y period indlt:llted. <br /> <br />ThiS pOliey is not stJbjar:tlo Cll_IJ$llon bythQ Fund QXc.pt upon 30 doyo odvlinCII wriltlin notice to the .mpley.,. <br />, <br /> <br />w. will also glve)'Oll 30 d'Y5ad""~ nolle>> S/lould Ihis policy b. canceUfOd p'iorto Itl; normal llXpilOlaon. <br /> <br />This =1I~art.' of Insu...nce Is not an inouranCII policy and don not emend, extend or alter the coverllg. a1fordod by the <br />policy listed herein. NOlWllhotanalng any 'equlremen~ term or condition at any contract or other doaument with <br />respeollo which IhT. certilicate or Insurance mey b. iSSIJ<d or!o ....hich it ""'y pl!!rtein, the inSIJtllnce m'furded by lIle policy <br />dHC/1bed herain i. subj.cllD .lIth. term..l'>llC!u'lon., .nd conditio"", of ~uch policy. <br /> <br />~ <br /> <br />J~c.~ <br /> <br />Al11"KORlZm lii~iiNT"'T'rV1 <br /> <br />fIftE~DENT <br /> <br />KKPLOfBR'S ~%AaI~rTY t!Mt~ !MCLDn!MG DB1ENSB ~bS~S. $1,000,000 ~~ OCC~~~. <br /> <br />ENDORSEMENT '~600 - ROGER FAUB!!L. ~RS, se, rR . EXCLUDED. <br /> <br />ERDORSEMBNT '~065 KNTITLBD CBRTI7ICAT2 HOLDERS' ROTICK 2FF2CTrvB 04-0l-~004 IS <br />ArrACXED TO AND FOllKll A PART OP THIS POLICY. <br /> <br />~.u*; <br /> <br />IMPI.OTOR <br /> <br />!loon FAUBEL PUBLIC AJ'UIR!I IIIC DIA. WATERS . J'AUBIlr. <br />2! OIlCHAm> <br />I.1oXI2 POUIl'%' CA g~ 630 <br /> <br />~~J:n..u.2004 <br />