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<br />~eb .P.OS 03:55p <br /> <br />Tllagl <br /> <br />IV - ;;LOO&- -lot <br /> <br />CERTHOLDER COpy <br /> <br />STATE <br />COMPENSATION <br />INSURANCE <br />FUND <br /> <br />P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 <br /> <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> <br />ISSUE DATE: 02-19-2009 <br /> <br />GROUP: 000236 <br />POXY NUMBER: 0006262-2006 <br />CERTIFICATE ID: 130 <br />CERTIFICATE EXPIRES: 01-01-2010 <br />01-01-2009/01-01-2010 <br /> <br />THE CITY OF SANTA ANA <br /> <br />20 CIVIC CENTER PLZ M-26 <br />SANTA ANA CA 92701-4066 <br /> <br />SG <br /> <br />~OB:TC9-003 BABY CHANGER INSTALLATION <br />1000 EAST SANTA ANA BLVD. <br />SANTA ANA <br />CA 92701 <br /> <br />Thlss to certify that we have issued a valid Workers' Compensation insurance policy in .a form Clpproved by the <br />C.ilifornia I"su,'i.lnce Commissioner 10 the employer named below for the policy period indicated. <br /> <br />This policy is no~ subject to cancellation by the Furd except upon SO days ad....ance wr'tten notice to the employer, <br /> <br />We will <Iiso give you ::10 d.RYS .dv..nce notjc~ should this policy be cancelleo prior to its norm::.! e"'pir.ation. <br /> <br />This certif,cate of insurance '5 not an Insurance policy and does not amend, extend or alter the coverage affOlded <br />by the policy listed he'ein. Notwithstanding any requirement term or condition of any contract or other document <br />with resDect to which this certificate of Insurance may be issued or to which it may pertain, the Insur.ance <br />afforded by the policy described 1erein is subject to all the terms, exclusions, and conditions, of such policy. <br /> <br />d::"EPRESENTATI ~E~ <br /> <br />EMPLOYER'S LIABILITY LIMIT INCLUDING OEFENSE COSTS: $1,000,000 PER OCCURRENCE, <br />ENDORSEMENT #001S ENTITLED ADDITIDNAL INSURED EMPLOYER EFFECTIVE 2009-02-19 IS <br />ATTACHED TO ANO FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: <br />THE CITY OF SANTA ANA <br />ENDORSEMENT #1600 - PICHON, BERNARD W P,S T EXCLUDED. <br />ENDORSEMENT #1600 - BARRON, FELIPE VICEPRES EXCLUDED. <br />ENDORSEMENT #2065 ENTITLEO CERTI~ICATE HOLDERS' NOTICE EFFECTIVE 01-0'-2009 IS <br />------ ATTACHED TO AND FORMS A PART OF THIS POLICY. <br /> <br />- <br /> <br />o fORM <br />A.PPROVED AS T <br /> <br />/ ~/ <br /> <br />- <br /> <br />-.J -- <br />/ '~aura SUlt :,,,ecdy <br />Assistant City Attorney <br /> <br />EMPLOYER <br /> <br />GAfF GROUP, INC AND/OR TRI-CDUNTY ORYWALL & <br />INTERIORS INC. <br />660 S STATE COLLEGE BLVD <br />FULLERTON CA 92891 <br /> <br />[BtE.SPj <br />PRINTED 02-19-2009 <br /> <br />(REV.2-051 <br /> <br />p.2 <br /> <br />SG <br />