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CERTHOLDER COPY <br />SC <br />P.O. BOX 420807, SAN FRAIVCISCO,CA 94142 -0807 <br />CERTIFICATE OF WORKERS' COMPEiVSAT10N INSURANCE <br />ISSUE DATE: 02 -07 -2011 <br />CITY OF SANTA ANA SC <br />PLANNING AND BUILDING AGENCY <br />PO BOX 1988 <br />SANTA ANA CA 62702 -1966 <br />GROUP: <br />POLICY NUMBER: 168186t -2010 <br />CERTIFICATE IIX 21 <br />CERTIFICATE EXPIRES: OB -01 -2011 <br />OB -01- 2010/06 -01 -2011 <br />This is to cerilfy that we have issued a valid Workers' Compensation Insurance policy In a form approved by the <br />Callfornfa Insurance Gommisslonar to the employer Hamad below for the policy period Indicated. <br />This policy is not subject to eaneellatton by the Fund except upon 30 days advance wrlitan notice to the employer. <br />We wilt 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. Notwifhstandin9 any requirement, term or condrilon of any contract or other document <br />with respect to which this certificate of insurance may be issued or to whleh It may pertain, the {nsuranca <br />of forded by the policy described hareln !s SubJect to all the terms, exclusions, and conditions, 01 such policy. <br />Authorized Representative President and CEO <br />EMPLOYER'S L3ABILITY LIMIT INCLUDING DEFENSE COSTS: $i,000, 000 PER OCCURRENCE. <br />ENDORSEMENT N20B6 ENTITLED CERTIFICATE HOLDERS NOTICE EFFECTIVE OB- 01 -20i0 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />VE AS TO FORM <br />RY .H E <br />A�rney <br />EMPLOYER <br />CENTURY STRUCTURAL ENGINEERING GO. INC. SC <br />24719 NARBONNE AVE - <br />LOMITA CA 90717 <br />(MJL,CN] <br />PRINTED 02 -07 -2017 <br />IRE V.g -20t0) ' <br />