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DyraR. ALLIANT <br />Ueanae Nltwbar: OC36861 <br />phone (949) 736.Y271 I Fats (949) 756.2113 <br />Date: 1/240 <br />CaEftcateNumbat043 VgpMORJCONTRACTORLIABILITYPRO <br />GRAM <br />Named Wumd: <br />Addm/a: <br />citAddmmzl ll> <br />Caonaat TOM From: <br />Description of Conaut: <br />TOM BYSTRY <br />3058 WESTHAVEN STREET <br />OgANGE, CA 92963 <br />CITY OF SANTA ANA <br />02101105 TO02101106 <br />VDIBO TAPING CITY 00UNCIN'TINGS <br />Cortnet Amount; - $45,760.00 <br />cobflHRRCIAL GBNE,RAI I.IABILtI'Y— <br />NZy 0CCURRl4NCB FORM <br />s1.000.000• <br />GPro&zucomIvw Opmuoaa limit 91^�. <br />Paraooal Adverd ' 51.000.000. <br />�1t tx�: s 50 AM. <br />Fire Dump: S 5+000 <br />Medieal Paynwim <br />T <br />Cot aayes are Lioalted to dtscnoed ccatraU. <br />DEDUCTIBLE: $1,000. Bttclt C,m• lmludioa IRpI and Adj °Em <br />libweptiolt <br />ANNUAL PAEMIDAI: $ 22-12 FUIIY road at Ioaepbar <br />SURPLUS LINES TAX: i 2 � fu11Y emod at IWCP*m <br />POLICY FEE: S75LI2 <br />TOTAL <br />MPANY <br />COMPANY; COLONY INbUWLMQ CO <br />CB S IPULAT D T}T>s POLICY <br />AIiY BII8D6 IHB S) OL%COMU IdS, AND LII'MATIONS OF SOUP. A <br />CEISSUBJLtCTTOTIETIOtMS. �gACTORSLiABLITY <br />OFMASfHRPOLICY9(�s 9215216ISSUEDTOV�1DO <br />COPY OF THIS POLICY IS AVAU ABLB ONREQUESTTHIS <br />y THE INSUREBY SURRENDER OF ATI <br />LL <br />THIS CERTIITCON WILL <br />ATS MAY BB CAN TO O�XD FLIBCO7 Own STATING WI N C A CE BY NOTICE TOTO <br />BINDERCmT[VBY TMCBRI FICC�ATEM�AYi CANPOLICY SONS <br />To INS�ry�J� i�•�fW'M� �IGNA[Z7Rfi <br />AIlRiORIZEDSI'C'14A ;r'i'ROV61) AS TO FORM <br />0.t> CW.tX R MATS UiSURANCE Sn0teas <br />t3aMa Nutben 6136213 <br />41 Cuya�' Sulb S l0.Yvitr.�ji23 i1'R <br />1, �ME(WM241TJ / FAX (W "auta Stitt S edy <br />A wm tant City Attorney <br />