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CERTHOLDER COPY <br />P.O. BOX 420807, SAN FRANCISCO,CA 94 ~ 42-0807 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: OB-01-2010 GROUP: 000497 <br />POLICY NUMBER: 0001634-2009 <br />CERTIFICATE ID: 97 <br />CERTIFICATE EXPIRES: OB-01-2011 <br />06-01-2010/06-01-2011 <br />CITY OF SANTA ANA <br />305 E 4TH ST STE 201 <br />SANTA ANA CA 92707-4638 <br /> <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 70 days advance written notice to the employer. <br />We will also give you 10 days advance notice should this policy ba cancelled prior to its normal expiration. <br />This certificate of insurance is not an insurance policy and does not amentl, 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, antl conditions, of such policy. <br />~~ v~~~t- <br />thorizad Representative Interim President and CEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT !!1600 - TRUJILLO, SAGAS, P,S T - EXCLUDED. <br /><al'1'ROVED AS TO FORM <br />~ >. ~, <br />_ --- <br />~ -~.~,~ `mac <br />c_aura Stit heedy <br />~~, a~t~utnt Ciiy Attorney <br />EMPLOYER <br />SUPERIOR PAVING COMPANY, INC. AND/OR PRESTIGE <br />STRIPING SERVICES INC, DBA: PRESTIGE STRIPING <br />SERVICES <br />14660 INDUSTRY CIR <br />LA MIRADA CA 90638 <br />(B13,SK] <br />PRINTED 06-29-2010 <br />SJ <br />(REV.I-2010) <br />