Insurance - Atlas Underground - 1994-12-01 STATE P.O. BOX 420807 SAN FRANCISCO CA 94142-0807
COMPENSATION
INSURANCE
FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
DECEMEc4 1. 19c4 1195872 - 94
POLICY NUMBER:
I CERTIFICATE EXPIRES: F-1-9c
l
COSTA MESA SANITARY DIST2IrT
77 FAIR. DRIP-
COSTA 71 SA CA 92629
JOB CMSD PRCJECT#1112100-135
EMP. 5-6
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.
PRESIDENT
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EMPLOYER
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HECTOF LOYA AND CHRISTY LCYA
DBA ATLAS UNDERGROUND CC
P.O. COX 951
CHINO CA 91708
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