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CERTHOLDER COPY <br />SQ <br />STATE P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 <br />COMPENSATION <br />INSURANCE <br />FUND 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- 2009/04 -01 -2010 <br />CITY OF SANTA ANA SO <br />PO BOX 1988 <br />SANTA ANA CA 92702 -1988 <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 policy Is not subject to cancellation by the 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 on 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 />Ti-IORIZED REPRESENTATI PRESIDENT <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE, <br />ENDORSEMENT #1600 - WHITECOTTON, ROBERT P,S T - EXCLUDED. <br />ENDORSEMENT N2085 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 04 -01 -2008 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />pppR4V D AS TO Folzm <br />.. Laura Stls� Shoedy <br />Assistant City Attorney <br />EMPLOYER <br />MASTER LANDSCAPE & MAINTENANCE, INC. SG <br />10171 NORTHAMPTON AVE <br />WESTMINSTER CA 92883 <br />1B1 E,SPj <br />iREV.2.0e1 PRINTED : 07 -02 -2009 <br />