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POLICYHOLDER COPY <br />P_O_ BOX 420807, SAN FRANCISCO,CA 94142 -0807 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 10 -04 -2010 <br />CITY OF SANTA ANA <br />20 CIVIC CENTER PLZ RM 429 <br />SANTA ANA CA 92701 -4058 <br />GROUP: <br />POLICY NUMBER: 1 7 1 4034 -2010 <br />CERTIFICATE ID: 63 <br />CERTIFICATE EXPIRES: 10 -04 -2011 <br />10 -04- 2010/10 -04 -2011 <br />SP JOB: MANHOLE SPRAYING FOR ROACH CONTROL <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 SO 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 />�� �� <br />thorized Representative In[Brlm President and GEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: 51,000,000 PER OCCURRENCE. <br />ENDORSEMENT #1600 - MURRILL ADAMS, PRESIDENT - EXCLUDED. <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 10 -04 -2003 IS <br />ATTACKED TO AND FORMS A PART OF THIS POLICY_ <br />APPRUULi� AS TU FUl2M <br />aura Stitt S' -�dy <br />Assistant City �� Llo rn '�i <br />EMPLOYER <br />GOLDEN BELL PRODUCTS, INC SP <br />1200 N JEFFERSON ST STE M <br />ANAHEIM CA 92807 <br />M0410 <br />IREV.7 -2070) <br />PRINTED 09 -17 -2010 <br />SP <br />