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POLICYHOLOERCOPY <br />BP <br />PO aos asasaT, sAN FArh'clsco,cA 941A2 -asoT <br />CERTIFICATE OF WOAMEAS' COMPENSATION AJSUAANCE <br />ISSUE OAiF; 00 -28 -9011 GPWP, <br />POLICY NUMBER 141881 <br />CERTIFICATE ID: 941 <br />CERiffICATE E%PIRE& 07- 01.9011 <br />07.01. 9011/07-01.9019 <br />CITY OF SANTA N14 • BRIAN IOE SP JOB:GTALINE STAEEi PUMP <br />A DIAMOND PPA( INPRDV <br />990 B CAISY AVE SANTA ANA <br />BANTA ANA CA 89700.4004 CA 8970.1 <br />This Is yo Cwtlfy tNt we hrva lasuad a valid Workers' Goypessetlm loauresu policy to s loan pprwed by Oe <br />Cilllornia 4uurance CommHsionar to the employe coned helow fa the policy period lodlcried, <br />This Doliey Is nel suhjel to carcellalion by Oa Wrd except upon 99 drys advance WriOen nolke to Ue employer. <br />We will also glue VW 80 days advance mtice should this pollry he cancelled prbr to Its normal expiration <br />ihls cerlNlcBle of 'msuranoN Is not an ifduraMe polity ed doss cot arced, extend or alter the wveage afforded <br />by the polity listed herein Notwi0.ahnd'ng am requirement term a ooaStan of any contract or aRer docmeul <br />wIN respect to wiJah cola cerlifloAe of Psvnce may ha issued Or la whloh If may pertd0, Ne Insurance <br />afforded by Ihs policy deacdEAd herein h aubjast to all Ae terms�ex�alutlom, �d oordMans, of ouch polity. <br />1'WIIOa El�,y <br />Authorised Rapreseowlve Prasldenl and CEO <br />EIPLOYER'B LIABILITY LINK INCLUOINO DFPENSE DOSTS: f1,000,000 PER ODARRENCF, <br />EPLORSEIMNi R0016 ENTIILED p001T10NAL INSURED EMPLOYER EFFECTIVE 9011 -W-98 IS <br />AIIACXED TO AND FOTASS A PART OF THIS POLICY. BANE OF ADBITIONAI IN$URFO, <br />C[tt OF SANTA R94 • BRIAN IRE <br />ENDORSEMENT 91800 • PpiAIC1A PAOlLLA P S T • EECLUDED. <br />ENBORSEMEMi A9089 FNI[iLEO CERTIFICRTE ROWERS' NOTICE EFFECiIIR 07-01 -90D9 IS <br />AiiACXEO TO ANO FORM$ A PAki OF THIS POLICY. <br />I #PFkuvuu Aa 1'U FUIUYa <br />EMPLOYER <br />roa.�:r qtly Allonm; <br />PAOILl4 A9L ABBOCIAiES IBC SP <br />911 E CITY PLACQ DR <br />BMTA ANp CA 8970fi <br />IPfssPj <br />PRIM¢O :09.98.9011 <br />puu.aaetN <br />