Insurance - Grbavac - 1994-02-03 STATE P O. BOX 420807 SAN FRANCISCO, CA 94142-0807
COMPENSATION
I N SU RwA ONCE
FUG V CO CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
B C RUARY 3 19 4 POLICY NUMBER: U _
CERTIFICATE EXPIRES. _
I-
CI Y OF COSTA 'IESA
DEPT OF bUILL1l.0 & SAF
2 E 7TH ST #2U2/
OSTA ES CA 2 27 JuB EMPLO E
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This is to certify that we have issued a valid Workers Compensation insurance policy in a form approved by the California
Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon ten days advance written notice to the employer
We will also give you TEN days advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the
policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other document with
respect to which this certificate of insurance may be issued or may pertain, the insurance afforded by the policies
described herein is subject to all the terms, exclusions and conditions of such policies.
PRESIDENT
EMPLOYER S LIABILITY LIMIT S3 000 000 PER OCCURRENCE
AppracriED AS TO FORM:
AT7 RyEY FO ISTRICT
EMPLOYER
P
GO & GORDOI+ GREA AC CONS CO I C
U319 F HER ST
TEMPLE CITY CA 91 / SU
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SCIF 10262(REV 10-86) /LAP-YAW W ROSE --1-N$L'C41 Ut AtreJrr S(/gy.755-1_ 9000
STATE P.O BOX 420807 SAN FRANCISCO, CA 94142-0807
COMPENSATION
INSURANCE
FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
FEBRUARY 4 , 1994 POLICYNUMBER• 1169289 — 93
CERTIFICATE EXPIRES. 9_1_9 4
r
CITY OF COSTA MESA
SANITARY DISTRICT
234 E 17TH ST #205
COSTA MESA CA 92626 JOB 2 EMPLOYEES
L
This is to certify that we have issued a valid Workers Compensation insurance policy in a form approved by the California
Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon ten days'advance written notice to the employer
We will also give you TEN days advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the
policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other document with
respect to which this certificate of insurance may be issued or may pertain, the insurance afforded by the policies
described herein is subject to all the terms, exclusions and conditions of such policies.
cjiiti
PRESIDENT
EMPLOYER S LIABILITY LIMIT S3 000 000 PER OCCURRENCE
EMPLOYER
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GREGO & GORDON GRBAVAC CONST CO INC
481 PI LONGDEN AVE
ARCADIA CA 91007
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SCIF 10262(REV 10-86)