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CERTHOLDER �Y <br />P.O. BOX 420807, SAN FRANCISCO,CA 94142 -0807 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 09 -28 -2011 <br />CITY OF SANTA ANA - BRIAN ICE <br />220 S DAISY AVE <br />SANTA ANA CA 92703 -4334 <br />GROUP <br />POLICY NUMBER: - 1 4 1 9866 -201 1 <br />CERTIFICATE ID: 241 <br />CERTIFICATE EXPIRES: 07 -01 -2012 <br />07- 01- 2011/07 -01 -2012 <br />SP JOB :CATALINE STREET PUMP <br />S DIAMOND PARK IMPROV <br />SANTA ANA <br />CA 92703 <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 30 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 termsc, /�e)�x cal u�s�i�o ns, and conditions, of such policy_ <br />°�'.r^ �� <br />Authorized Representative President and CEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2011 -09 -28 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY_ NAME OF ADDITIONAL INSURED: <br />CITY OF SANTA ANA - BRIAN ICE <br />ENDORSEMENT #1600 - PATRICIA PADILLA P 5 T - EXCLUDED_ <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 07 -01 -2002 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY_ <br />EMPLOYER <br />PADILLA AND ASSOCIATES INC <br />211 E CITY PLACE DR <br />SANTA ANA CA 92705 <br />�F'�'jltl� V �i� „4S "TlJ FC3iZNi <br />--'� —�-�ti tt: Sttccdy <br />:"h FS1s LY7 ni C.it -y Attorn cti <br />SP <br />M0408 <br />(RE V.B -20t0) PRINTED 09 -29 -2011 <br />SP <br />