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~.: - -- <br />i <br />.. _._.., <br />.' ~ '-~ ,' <br />P.O. BOX 420807,, SAN FRANCISCO, CA 94142-0807 ' <br />STATE ~-.. <br />COMPENSATION <br />IN-8URANCE f.~:.<:. - <br />.:.: , . <br />V N ~ CERTIFICATE OF WORKERS' COMPENSATIONfNSUR~-NCE <br />,_ ~ , <br />.JUNE 15', L 9 ~,~ - k ~ POUC~rtvuM~ER: 1 Q x,14 7 5 - 9 5 <br />. , CERTIFICATE EXPIRES:. S'-1-9 6 tt-. -----~^-, <br />~ ~ ~•~~~ X1'^5 Y / ~ <br />~., a <br />v <br />..,,, Z <br />-: eITY •OF S1Cial"~~l .ANA ,- Q.Y . <br />.. <br />_ - ~~ . .: <br />5 %S <br />_ .. •; _ <br />y :. <br />t~. ~?E~.T:_OF _.9iITf~"ltls hND`.SAFSgY` .,.. <br />- -~~ZUb~- li~tES'T. 'FO~B'~`S.'F~REE7'' _ ~ Z~^ c~ <br />"SANTht` .ANAL Cl-G . .9~?T02 .i0$'. 2 £MPL41rESS ~-C <br />L" , _ 3 -. - <br />...~ _ _ <br />This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California <br />_ Insurance Commissionerto the employer named below for the poli~~eriod indicated. _ <br />Tt~jg policy is not subject to .cancellation by the Fund except upon t~ifsrdays' advance written notice to the employer. <br />3fl <br />We will also give you T~19 days' advance notice should this policy be cancelled prior to its normal expiration. <br />This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the <br />policies listed herein. Notwithstanding -any requirement, term,. or condition of any contract or other document with <br />' respect to which -this certificate of insurance may be issued or may pertain, the insurance affacded by the policies <br />' .described herein>is ubject to all the terms, exclusions and conditions: of such policies_ <br />- ._ . <br />PRESIDENT <br />• __£MPLOYER'S LIAi3ILITY LIMIT INCLUDING DEFENSE ~CSTS: ~i,COr),©QJ P£R OCCURRE:iCE <br />ENDORSEMENT #OOI5 ENTITLED XDDiTIQN.~1. INSURED EMPLOYER ~:EFECTIVE <br />06/1593 IS AT'T-ACHED TO ANII FORMS A PART OF THIS POLICY. } <br />NAME OF 'ADDITIONAL INSURED.: CITY OF SANTA ANA r <br />.~ .. \ <br />ENDORSEMENT #206.5 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVs^, <br />.Qfrf15/95 IS ATTACHED TO AND FORMS-A PART OF THIS POLICY. <br />_ _ ,.~ <br />~- SPE'CIHEf ENDORSEMENTS #OOIS ~i~D #20b5'ATfilCCHED: -'- - - - - <br />.,_1. _ <br />- - _- ,.. _ <br />::.:v..^. ~ -. - - - .. <br />'~L - - - <br />-a .. <br />,_ - <br />... ., ~ .: <br />-Y..v. '.. _~ dti - <br />~: ~ {,_ - <br />' ;: f ... ~ EMPLOYER ~ <; >• • ~ <- ' - .; +~,>>` <br />-_ _, ~ - ~: <br />r <br />... <br />r - - <br />~: <br />.... <, _ <br />*GOLDEN l7£AIt(YWS, CONSTRUCTI'U!y'`, _ _ ~ Y <br />.:.. <br />~; .,. <br />_ >.. <br />- ACE' FENCE ~O:", _. <br />,~ ., .. _ <br />.- <br />- -- <" ~_; jar:. <br />~~ 51-35::;:.SALT ~K' ~AVE .. . <br />,IcA ~:~ <br />IND~OSTRY C1i+~ 9`I746 _ - _ <br />- tlJ:..- ~,~ <br />