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<br />.. <br /> <br />SP <br /> <br />STATE <br />COMPI;NSATIOIiI <br />INSURAtolCiE <br />FUND <br /> <br />.... <br /> <br />\oJ <br /> <br />P,O, SOX 807; SAN FRANCISCO,CA 94101-0807 <br /> <br />CERTIFICATE QFWOFlKERS' CO~PENSATIONINSURANCI!' <br /> <br />ISSUE DATE: 10-01-02 <br /> <br />POLICY NUMBER: 120~851 - 02 <br />CERTIFICATE EXPIRES: 10-01"03 <br /> <br />CITY OF SANTA ANA <br />COMUNITY DEVELOPMENT AGENCY 1\-25 <br />P.O. BOX 1988 . <br />SANTA ANA <br />CALIFORNIA 92702-1988 <br /> <br />~08: A~~ OPERATIONS <br /> <br />This is to certify tflatwehave issued' a valid Workers' Compensation insurance policy in a. form 'approved by the <br />California Insurance Commissioner to the employer named below for the polieyperiod indicate:CL <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""sd,vance notice should this policy be<caJ'!lceUedprtor toits.:-normalsxpiration. <br /> <br />. - . <br />This certificate6fjnsJr~nce "is pot -_,~n -in~ur;an~e 'POliCY,:an(t ','does nOl.amtJnd~;: ex~en&Or~ltt:!~;tftecoyerag~afforded <br />by the policjes" listed her&in,-!SJQtwfdl$tan~ini'any,r4':qJ.liriUJ\eJnt... term,orconditiol"t'Q;f...8Tl)'..conk4Qtor' other document <br />with resp~ct to ,which this certificate of insuranI?6 rnaV,:,;b,,'~~_~ued or may pert~jn,>~th~lnsuranee afforded by the <br />policies de~cribed herein is SUbject to all t~e;terms. exclusicms and conditions of such policies. <br /> <br /> <br />~IDE~ <br /> <br />EMP~OYER'S ~IAII~JTY ~IMJT INC~UOING DEFENSE CDlIT$: $1;qP("'~0,0() P,~R ;O~RENCE. <br /> <br />ENDORSEMENT #2085 ENTIT~EO CERTIFICATE HO~OERS'lilPTJc;.E eFFEcltVE.1l)/01/Q2 IS ATT!\CH.EO .TO ANO <br />FOR~S A PART OF THIS POL~CY, <br /> <br />APPROVED AS TO FORM <br /> <br />Gif:t~nQ~ <br />aura.Sl)e~~ ..... <br />Deputy City AtiorheY <br /> <br />EMP~OYeR <br /> <br />LEGA~ NAME <br /> <br />THOMAs }IOUSE TEIIPORARYSHELTEIl <br />PO BOX 2737 ; <br />GAROEN GROVE CA ~2842 <br /> <br />'.::C-.,J <br />. THOMAS HOI.($E TeMPORARY $HEL TER <br />(A NON-PR01'1lT ORCa,) <br /> <br />01-11-02 <br /> <br />-: ~ . .. . ' . : <br />THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND selF 10265 (RLV 201) <br />