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p- 2000v - /O 2 <br />CERTHDLDER COPY <br />ISSUE DATE= 10-01-2009 <br />CITY OF SANTA ANA <br />PUBLIC WORKS AGENCY <br />20 CI VZC CENTER PLZ M-38 <br />SANTA ANA CA 92701-4058 <br />P.O. BOX 420807, SAN FRANCISCQCA 94142-0807 <br />SG <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />GROUP: <br />POLICY NUMBER: 08 02 8 47-2009 <br />CERTIFICATE ID: 4'19 <br />CERTIFICATE EXPIRES: 10-01-2010 <br />10-01-2009/10-01-2010 <br />SG JDB:ALL CALIFORNIA SITES <br />This is to certify that we have issued a valid Workers' Compensation insurance policy in a Corm approved by the <br />California Insurance Commissioner to the employer named below for the policy period indicated. <br />This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. <br />We wUl also give you 30 days advance nauce should this policy be cancelled poor to its normal expiration. <br />This cerliflcate of insurance is not an insurance policy and does not amend. extend or altar the coverage afforded <br />by the policy listed herein Notwithstanding any requirement. term ar condition of any contract or other document <br />with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance <br />afforded by the policy described herein is subject to all th6\?t\??.rms?. ??`x'?c/?usions, and conditions. of such policy. <br />(J <br />THORIZED REPRESENTATI PRESIDENT <br />EMPLOYER'S LIA6ILITY LIMIT INCLUDING DEFENSE COSTS: 51,000,000 PER OCCURRENCE_ <br />ENDORSEMENT !/1600 - JAMES K_ CAIN, PRESIDENT - EXCLUDED. <br />ENDORSEMENT 820®B ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 10-0?-1993 IS <br />ATTACHED TD AND FORMS A PART DF THIS POLICY. <br />EMPLOYER <br />J 8 G INDUSTRIES, INC_ AND/OR GAIN, JAMES K. <br />(AN IND.) <br />7BY1 SU2I LN <br />WESTMINSTER CA 92683 <br />M0408 <br />PRINTED 09-17-8009 <br />(RE V.2-051