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CERTHOLDER COPY <br />SC <br />' ZCtPI A.f'� 2� ,mM 11= 26 <br />P.O. BOX 420807, SAN FRANCISCO,CA 94142 -0807 <br />CERTIFICATE OF WORKERS' COMPENSATION WSlJRANC�( (c ; '° , �> T�' I':,� <br />t.:t.iL <br />ISSUE DATE: 02- 07-2011 GROVP: <br />POLICY NUMBER: 1661861 -2010 <br />CERTIFICATE ID: 21 <br />CERTIFICATE EXPIRES: OB -01 -2011 <br />OB -01- 2010/08 -01 -2011 <br />CITY OF SANTA ANA SC <br />PLfiNNINQ AND BUILDING AGENCY <br />PO BOX 1988 <br />SANTA ANA CA 62702 -1968 <br />This is to certify 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 subJect to cancellation by the Fund except upon 30 days advance wrlitan notice to the employer. <br />We will also Siva you 30 days advance notice should this policy be cancelled prior to its normal expiration. <br />Th15 certificate of Insurance is not an insurance policy and does not amend, extend or altar the coverage afforded <br />by iha policy listed herein Notw]thstanding any requirement, term or condition o1 any contract or other document <br />with respect to which ihls certificate of insurance may be issued or to which It may pertain, the Insurance <br />afforded by [he policy tlescribed herein !s subJect to all the terms, exclusions, and conditions, of such policy. <br />Authorized Represanfativa President and CEO <br />EMPLOYER'S LIABILLTY LIMIT INCLUDING DEFENSE COSTS: 51,000,000 PER OCCURRENCE. <br />ENDORSEMENT H2O86 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE OB -01 -2010 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />OV AS TO I��ORM <br />� o� � ll <br />! D_ HOD B <br />City Aq�y <br />EMPLOYER <br />CENTURY STRUCTURAL ENOINEERIN� CO. INC. SG <br />24719 NARBONNE AVE <br />LOMITA CA 80717 <br />jMJL,CNJ <br />PRINTED 02 -07 -2011 <br />wstr. a -zotol <br />