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CERTHOtDER COPY <br />STATE P.O. BOX 420807, SAN FRANCiSCO,CA 94142-0807 <br />COMPBNSA710N <br />IN SURANCS <br />F U N C~ CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE; 07-02-2009 GROUP: 000290 <br />POLICY NUMBER: 0002003-2009 <br />CERTIFICATE ID: 44 <br />CERTIFICATE EXPIRES: 04-01-2010 <br />04-01-2008/04-01-2010 <br />CITY OF SANTA ANA gp <br />PO BOX 1888 <br />SANTA ANA CA 82702-1888 <br />This Is to certify that we have issued a valid Workers' Compensation Insurance policy In a form approved by the <br />California Insurance Commisslaner 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 />Wa will also give you 30 days advance notice should this policy be cancelled prior to Its normal expiration. <br />This certificate of Insurance is not an (nsurance policy and does not amend, extend or alter the coverage afforded <br />by the policy listed herein. Notwithstanding any requirement, term or 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 />affarded by the policy described herein Is subject to ail the terms, exclusions, and conditions, o} such policy. <br />THORIZEb REPRESENTATI PRESIDENT <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: 11:1,000,000 PER OCCURRENCE. <br />ENDORSEMENT N1B00 - WHITECOTTON, ROBERT P,S T - EXCLUDED. <br />ENDORSEMENT N20BB ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 04-01-2008 IS <br />-~~ ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />APpROV~ll AS TO ~O121Vi <br />Laura Stl1~ Sh.eedy <br />Assistant City Attorney <br />EMPLOYER <br />MASTER LANDSCAPE i! MAINTENANCE, INC. SO <br />10171 NORTHAMPTON AVE <br />t1ESTMINSTER CA 82883 <br />(B1E,SP] <br />tFrEV.Y•e61 <br />PRINTED 07-02-2008 <br />SO <br /> <br />