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POLICYHOLDER COPY <br />P.O. BOX 8192, PLEASANTON, CA 94588 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 02-19-2015 <br />CITY OF SANTA ANA SD <br />12 CIVIC CENTER PLZ <br />SANTA ANA CA 92701-4057 <br />GROUP: <br />POLICY NUMBER: OB03749-2014 <br />CERTIFICATE ID: 1173 <br />CERTIFICATE EXPIRES: 10-14-2015 <br />10-14-2014/10-14-2015 <br />This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the <br />California Insurance Comrniss..oner 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 he 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 heroin. 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 #20e5 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 10-14-2002 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />EMPLOYER <br />PYRO SPECTACULARS, INC. SO <br />PO BOX 2329 <br />RIALTO CA 92377 <br />fe <br />�e��e d by <br />' i� <br />as <br />S\�vo G' Pdm�r <br />? <br />�1`1ev.v-20141 PRINTED : 02-19-2015 <br />