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<br />NA <br /> <br />POLICYHOLDER COpy <br /> <br />STATE <br />COMPENSATION <br />IN 5 UR A NeE <br />FUND <br /> <br />P.O. BOX 807, SAN FRANCISCO,CA 94142-.0807 <br /> <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> <br />CITY OF SANTA ANA <br /> <br />20 CIVIC CENTER PLAZA~ ROSS,ANNEX <br />SANTA ANA CA 92701 <br /> <br />NA <br /> <br />GROUP: <br />POLICY NUMBER: 1594126-2005 <br />CERTIFICATE ID: 104 <br />CERTIFICATE EXPIRES: 01-01- 2006 <br />01-01-2005/01-01-2006 <br /> <br />JOB: uOB 2422; 5APS <br /> <br />ISSUE DATE: 01-01-2005 <br /> <br />This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved 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 30 .days'advance notice should this policy be cancelled prior to its normal expiration. <br /> <br />This certificate o-t ,insurance is not an insurance policy and does not amend, extend or alter the coverage afforded <br />by the polici~slisted herein~'No:twithstanding any. rElguireJrnent, term. or condition of any contract or other document <br />with respect to vyhich this certificate of insurancernay be issued or may:pertain, the insurance afforded by the <br />policies described herein is subject to all the terms. exclusions and conditions of such policies. <br /> <br />~ <br /> <br />tl~C <br /> <br />~ <br /> <br />AUTHORIZED REPRESENTATIVE PRESIDENT <br /> <br />EMPLOYER'S LIABILITY LIMIT INCLUOING DEFENSE COSTS: $1,000,000.00 PER OCCURRENCE. <br /> <br />ENDORSEMENT #2065 ENTITL~O CERTIFICATE HOLDERS' NOTICE EFFECTIVE 01-01-2005 IS ATTACHED TO AND <br />FORMS A PART OF THIS POLICY. . <br /> <br />HEGE/IJt'C' <br />'5"" e=UJ <br /> <br />APPROVED AS TO hn. <br />'O^ r L <br />) ~ <br />< t\...e~ C:; ~.___._ <br />Laura Stitt Sb~'~~Y <br />Assistant City AllOj'I\.;\ <br /> <br />f1j.:.rEM~LOygfjO~ <br /> <br />LEGAL NAME <br /> <br />&. Wit if iA~~;;i\ <br />-"'",,"< _lJj~.!) <br /> <br />GORDON & WilliAMS GENERAL <br />CONTRACTORS. I NC. <br />2 FARADAY <br />IRVINE CA 92618 <br /> <br />G W G C, INC. <br /> <br />(REV.3-03) <br />~~\1.J.~,Rir~Mt~-""".,. <br /> <br />PRINTED, 12/17/2004 P0410 <br />'"""._ -- ~iQ;;: 1~"i1 &H){I>Hlhlll=l:'::~ ~i:l ~ ~'l..'ii7.tll :11!l ~I:N :1':'\'H!I ~:m~ I:I'Dl! :1tll~ ~<[~ ~KoIUli!ID)l',~V,;,'d~':',~,ir;-i'!;;-N}m*:@~~m.l. "'~f~f.~t;~~8 <br />