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POLICYHOLDER COPY <br />SG <br />P.O. BOX 8192, PLEASANTON, CA 94588 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 02 -18 -2014 <br />CITY OF SANTA ANA SG <br />BLDG INSPECTION DEPT <br />20 CIVIC CENTER PLZ <br />SANTA ANA CA 92701 -4058 <br />GROUP: <br />POLICY NUMBER: 9057937 -2013 <br />CERTIFICATE ID: 8 <br />CERTIFICATE EXPIRES: 07 -11 -2014 <br />07 -11- 2013/07 -11 -2014 <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 terms, exclusions, and conditions, of such policy. <br />Authorized Representative President and CEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br />ENDORSEMENT #1600 - PAKZAD, ALI PRESIDENT TREASURER - EXCLUDED. <br />ENDORSEMENT #1600 - PAKZAD, PAMELA SECRETARY - EXCLUDED. <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 07 -11 -2013 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />EMPLOYER <br />APA ENGINEERING, INC SG <br />9880 IRVINE CENTER DR <br />IRVINE CA 92818 <br />a,Pl'ROV�ll AS TO FU%' <br />Laura Stitt Sheedy <br />Assistant CitY Atlnr ", <br />[GNC,CN) <br />PRINTED : 02 -18 -2014 <br />(REV.1-2012) <br />