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POLICYHOLDER COPY <br />SC <br />P.O. BOX 420807, SAN FRANCISCO,CA 94 1 42 -0807 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 08 -11 -2011 <br />CITY OF SANTA ANA SC <br />PLANNING & BUILDING AGENCY <br />PO BOX 1988 <br />SANTA ANA CA 92702 -1988 <br />GROUP: <br />POLICY NUMBER: 158 1 661 -201 1 <br />CERTIFICATE ID: 22 <br />CERTIFICATE EXPIRES: OB -07 -2012 <br />06 -01- 2011/06 -01 -2012 <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 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 />Authorized Representative President and CEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 06 -01 -2010 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />AFRO TO FORM <br />/� 9 is /l <br />Y HOD['6 <br />nt Ap�e1•ey <br />EMPLOYER <br />CENTURY STRUCTURAL ENGINEERING CO. INC. SC <br />24719 NARBONNE AVE <br />LOMITA CA 90717 <br />[HI M,CN] <br />(aev.a -2o1o) PRINTED : 08 -11 -2011 <br />