Project 166 - Insurance - Sancon - 2004-08-06 Nig POMS and ASSOC Fa 1-818-876- 322 Aug 6 2004 14 32 P 01
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ACORQN CERTIFICATE OF LIABILITY INSURANCE I 08/06/200'
PRODUCER (818)876-3336 ' FAX (818)876-3321 THIS CERTIFICATE IS ISSUED AS A MATTER OP INFORMATION
Pours & Associates I ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
24025 Park Sorrento Attn Mary H Pavlo HOLDER,THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Suite #110 I
Cal abasas, CA 91302 1 INSURERS AFFORDING COVERAGE i NAIC#
INSURED Sancon Engineering II Inc INSURER A, Virginia Surety Company, Inc -A/IIX
5841 Engineer Drive INSURERD Liberty Insurance Underwriters a/XV
Huntington Beach CA 92649 INSURER C. American Int'1 , Specialty Lines A+/XV
1 INSURER,.
1 INSURER'D 1
COVERAGES I
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,TH INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGAT-LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR WCD'J� TYPE OFINSURANCE POLICY NUMBER I PO O9 aCn E PgL , X,,RA ONI LIMITS
��,Nqy ne. , Yrpry n -�NA t
GENERAL UAEIU1Y I I I EA OH CCCURRERCE _6 1,000,000
X COMMERCIAL :M=RnLLE:MLITT' IC0503.13200 10/01/2003 110/n1/2004 ,UA 1ASEiOPRENro 1 1 f 50,000
CLAIMS MADE ® OCCUR MED EXP(AND Person 1 5,000
A i PERSONAL AA '/INJURY 1 1,000,000
' IH^ I GENERAL AGGREGATE I$ 2,000,000
hilt AGGREGAT LIMIT APPLIES PER: PRODUCTS COMPIOPAGG I S 2,000,000
I n P°"71-1 jet 01 WC I
1 A-TOMDBUUAEIUlY I COM'DINED SINGLE LIMIT
I X ANY ALTO I (EA Scotia t) $ 1,000,0001
II— A .ONNE.AUTOS I I I BODILY INJURY I
H SCNE 'JLC AUTOS I 1CA50113300 10/01/2003 10/01/2004 I (Pero' n) s
A HIRE..AUTOS
BODILY INJURY $
X NON OWNS AUTOS IP earn)
PROPP-TY DAMAGE
I
(Pa.a omit) I6
i
CARAOEUAEILITY `ALTO ONLY-EA ANCPS.N. I a
ANY AUTO OTHER THAN EA ACC S
ALTO ONLY AGO O
EXEESSA7MGRELLALIASIUTY E .. -^N - 1 4,000,000
OCCUR E CLAIMS MACE AGGREGATE —1 s 4,000,000
B I L01-671181325013 10/01/2003 10/01/2004 I6
_ DEDUCTIEL_ $
R:TENTION E I I I6
I WORICRB COMPENSATION AND X I WCr1,b I°ThI
WC LICS rM
EMPLDYERS'LIABILITY E._.EACH ACCIDENT I$ 1,000,000
AANY PROPPIETOR/PARiNE € CUTIVE J
OFFICENN=MBEREXC_UDEO+I 10450113100 10/01/2003 10/01/2004 E.L.DISEASE EAMAPLOYE�5 1,000,000
Il yea.deaa0.Leder E.L.DISEASE POLICY LIMB 6 1,000,000
SPECIAL PROVISIONS calm CLAIMS MADE POLICY
nractor s Pollution CPL1176136 10/01/2003 10/01/2004 S1 000 000 Each Claim/Agg
C Liability (CPL)
I
DESCRIPTION Of OPEM,YJHS/L CATICNG i YFHICLE I EXCLL'810 S ADDS YON DRB•MFNT I SPEPIA PROVI31 Ne
e' Costa Mesa Sanitary D,stri�ct Pro ect �i12i00-2.66-Manno4e and Pump Station Rehabilitation
t is agreed that Costa Mesa Sanitary District is named as Additional Insured per the attached
endorsement
*10 Days Notice of CaIncellation Shall Apply for Non-Payment of Premium
CERT FICATE POLDER I CANCELLATION
1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES¢E CANCELLED BEFORE THE
EXPIRATION DATE THEREOF THE ISSUING INSURER WILL ENDEAVOR TO MAIL
Costa Mesa Sanitary District 30* DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
Attn loan Rgvak BUT FAILURE TO MAIL SEEN NOTICE SMALL INKIER NO ODLIGAnON OR LIABILITY
P.0 Box 12001 OF AN I UPON THE INSURER.ITS AGENTS OR REPRESENTATIVES.
Costa Mesa, CA 93628 AUTHORISED EN1TTA�TTIIVE/�(�'' / / 7 /)
ACORD 25(2001/08) G� V /(�) /../�(�°(CO�,RID///`C'/ORPORATION 1988
POMS and ASSOC F 1-81u-876-3322 Aug 5 2004 14 32 P 02
Costa Mesa Sanitary District
Certificate issued to Costa Mesa Sanitary District 08/06/2004
Moms & Associates
08/06/2004
Virginia Surety Company Inc - Admitted A/IX
Policy No 1CG50113200
Additional Insured dwners Lessees or Contractors (FORM B)
This endorsement modifies insurance provided under the following
COMMERCIAL GENERAL LIABILITY PART
SCHEDULE
Name of Person of Organ zation Costa Mesa Sanitary District
(If no entry appears above_ information -equired to complete this endorsement will be shown in the
Declarations as applicable to this endorsement )
WriO IS AN INSURED (Section II) is amended to ncl,:de as an nsured the person cr organization shown in
the Schedule, but Only with -espect to 1 ab' . a. .g out of 'you. work' for that insured by or t
you
ISO ENDORSEMENT ACC 20 10 11 85