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ISSUE DATE: 07.11 -2014 <br />CITY OF SANTA ANA <br />BLDG INSPECTION DEPT <br />20 CIVIC CENTER PLZ <br />SANTA ANA CA 92701 -4059 <br />POLICYHOLDER COPY <br />P.O. BOX 8192, PLEASANTON, CA 94566 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />SO <br />GROUP: <br />POLICY NUMBER: 9057837 -2014 <br />CERTIFICATE lo: 9 <br />CERTIFICATE EXPIRES: 07-11 -2015 <br />07 -11- 2014/07 -11 -2015 <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 91600 - PAKZAD, PAMELA, SECRETARY - EXCLUDED. <br />ENDORSEMENT #206S 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 <br />9880 IRVINE CENTER DR <br />IRVINE CA 92618 <br />SO <br />FORM <br />Jose Sandoval <br />Assistant City Attorney <br />M0409 <br />PRINTED : 06 -17 -2014 <br />(REV. 1 -2012) <br />sr. <br />