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POLICYHOLDER COPY <br />~~ ®~ P O. BOX 420$07, SAN FRANCISCO,CA 94142-0807 <br />GOMP6NSATION <br />INSIJFtANC~ <br />~~ ~ CERTIFfCATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 02-11-2009 GROUP: <br />POLICY NUMBER: 1339472-2009 <br />CERTIFICATE ID: 555 <br />CERTIFICATE EXPIRES: 01-01-2010 <br />01-01-2009/01-01-2010 <br />CITY OF SANTA ANA SP JOB:788-002 SAN LOREN2D LIFT STATION MND <br />220 S DAISY AVE <br />SANTA ANA CA 92703-4334 <br />This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the <br />California Insurance Commissioner to the employer named below for the policy period indicated. <br />This paficy is not subject to cancellation by fhe Fund except upon 30 days advance written notice to the employer. <br />We 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 insurance 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 />afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy <br />THORiZED REPRESENTATI PRESIDENT <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE C05T5: $1,000,000 PER OCCURRENCE, <br />ENDORSEMENT #/1600 - F.JAMES GRECO,PRES. -EXCLUDED, <br />ENDORSEMENT N1800 -GEOFFREY SCOTT, SEC. - EXCLUDED. <br />ENDORSEMENT N1600 -BARRY BURNELL,VP - EXCLUDED. <br />ENDORSEMENT N1600 -RUSSELL GARCIA,VP, - EXCLUDEb. <br />ENDORSEMENT 1/1600 -JOEL MORSE,TREAS, -EXCLUDED. <br />ENDORSEMENT {{1600 - FIROUZ GHABOUSSI,VP. -EXCLUDED. <br />ENDORSEMENT /12065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 01-01-1995 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />EMPLOYER <br />T & B PLANNING CONSULTANTS, INC <br />17542 17TH 5T STE 100 <br />TUSTIN CA 92780 <br />~ ~~,;, <br />~ y ~~ ~ ~l - <br />~~~ ~ <br />~ ~ <br />P+ ' ~aJ~~4~ G~`~ <br />5P ~SSlstia <br />IP1w.sPj <br />SP <br />ItiEV.z-ost PRINTED : 02-11-2009 <br />