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CERTHOLDER COPY <br />P.O. BOX 420807, SAN FRANCISCO,CA 94142 -0807 <br />CERTiF1CATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 02 -07 -2011 <br />CITY OF SANTA ANA SC <br />PLANNING AND BUILDING AGENCY <br />PO BOX 1989 <br />SANTA ANA CA 92702 -1968 <br />GROUP: <br />POLICY NUMBER: 1861861 -2010 <br />CERTIFICATE I6 21 <br />CERTIFICATE EXPIRES: OB -01 -2011 <br />OB -Ot- 20]0/08 -07 -2011 <br />This Is to ceruty that we have issued a valid Workers' Compensation Insurance policy In a iorm approved by the <br />California Insurance Commissioner to the employer named below for the policy period Indicated. <br />This policy Is not subJact 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 poltcy be cancelled prior to Its normal expiration. <br />This certi /icate of Insurance is not an insurance policy and does not amend, extend or alter the coverage afforded <br />by the policy listed herein Notw7thstanding any requirement, term or condition of any contract or other document <br />with respect to which this certf flcate of insurance may be Issued or to which It may pertain. the insurance <br />afforded by the policy described herein Is subJact to all the terms�e�x���usioncs, and conditions, of such poltcy. <br />t r `H)W�a L �yy� <br />Authorized Representative President and CEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT NZOBB ENTITLED CERTIFICATE HOLDERSr NOTICE EFFECTIVE OB -01 -2010 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />EMPLOYER <br />CENTURY STRUCTURAL ENGINEERING CO. INC. SC <br />24719 NARBONNfi AVfi <br />LOMITA CA 90717 <br />(MJL,CNJ <br />PRINTED 02 -07 -20]1 <br />IRE V. H•1010) <br />SC <br />