03-0911_ALEXANDER ENGINEERS, INC._Insurance Certificate9/11/03 1:25 PM 1-510-452-2193
19494931053 002
Al FYAFNr:I
, V Y LRFfV
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITISTANDIN
CERTIFICA OF LIABILITY INS NCE
09/iiros D,YYI
PRODUCER
Dealey, Renton & Associates
THIS CERTIFICATE IS ISSUED .AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
199 Los Robles Avenue #540
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
Pasadena, Ca 91101
626-844-3070
INSURED
INSURERA: United States Fidelity & Guaranty
Alexander Engineers, Inc.
INSURER B: St Paul Fire & Marine
502 W. Alosta Avenue #17
INSURER C: Great American Assurance Co.
INSURER D:
Glendora, CA 91740
L�' Q
INSURER E:
, V Y LRFfV
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITISTANDIN
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISS17ED 0
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUC.
POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE. BEEN REDUCED BY PAID CLAIMS.
NSR
POLICY
POLICE E
LIMITS
TYPE OF INSURANCE
POLICY NUMBER
A
GENERALLIABILITY
BKO1226262
EE�FFECTIVE
10/16/02
nPIRATION
MX
10/16/04
EACH OCCURRENCE $1 000
PIER DAMAOB(Anyonetl,e) $1000000
X COMMBRCIALGENERALLIABILITY
MED EXP (Any ore 'o' &10000
CLAIMS MADE NIOCCUR
PERSONAL&.ADVINJURY $1000000
GENERAL AGGREGATE $2000000
GEN'LAO OREGATR LIMITAPPLIHS
PER:
PRGDUCIS -COMP/OP.AGG 12 OW 000
1-1
FR(}
POLICY F7IF
A
AUTOMOBILE
LIABILITY
BKO1226262
10/16/02
10/16/04
COMBINED SINv'LH LIMIT $1,000,000(Eaucid
I)
ANYAUTO
ALL OWNED AUTOS
BODILY INJJRY $,
7 ' '-on)
SCHEDULED AUTOS
BODILY INJUIC'
$
X
HRED AUTOS
X
ff'.v acci&n0
NON-0WNED AUTOS
PROPERTY LAMA �F $
GARAGE LIABILITY
AUTO ONLY. EAACCIDENT $
CTHER THAN EAACC $
ANYAUTO
AUTOONLY: AGG S
EXCESS LIABILITY
EACH OCCURRENCE S
AGGREGATE $
OCCUR FICLAIMSMADE
L
S
DEDUCTIBLE
$
RETENTION $
B
WERS COMPENSATION AND
WORKERS
WVA7724714
09/01/03
09/01/Mn 0-�
X WC SIATU- ".ITS
RE
B.L. EA,'H ACC9DENT $1000000
B
EMPLOYERS' LIABILITY
ei..DISEAS'E-HAEMPLOYER $1,000000
E.L.DISEASH-POLICYLIMIT 0,000,000
C
OTHER Professional
EDN320854703
10/16/02
10/16/03
$1,000,000 per claim
lability
$1,000,000 annl aggr.
DESCRIPTION OF OPERATIONS'LOCATIONS/V EHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
The City of San Juan Capistrano Is named as an additional insured as
respects general liability for claims arising from the operations of the
named Insured.
City of San Juan Capistrano
Public Works Director
32400 Paseo Adelanto
San Juan Capistrano, CA 92675
LD ANYOFTHEABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHEEX'PIRVFION
THEREOF, THE ISSUING INSURER WILLXX MAIL30—DAYS WRITTEN
CERTIFICATE HOLDERNAMEDTOTHE LEFT,
9/11/03 1:25 PM 1-510-452-2193
•
Policy Number: BKO1226262
Owners Lessees or Contractors (Form B)
ADDITIbNAL INSURED
Change(s) Effective: 09/11/03
19494931053
•
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT
CAREFULLY. This endorsement modifies insurance policy under the following:
LIABILITY COVERAGE PART:
Schedule
Name of Person or Organization:
City of San Juan Capistrano
Public Works Director
32400 Paseo Adelanto
San Juan Capistrano, CA 92675
SECTION II - WHO IS AN INSURED is amended to include as an insured the
person or organization shown in the Schedule, but only with respect to liability
arising out of "your work" for that insured by or for you.
CL/BF 22 40 03 95
003
9/11/03 1:25 PM 1-510-452-2193 19494931053 004
Policy Number: BKO1226262
Owners Lessees or Contractors (Form B)
ADDITIbNAL INSURED
Change(s) Effective: 09/11/03
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT
CAREFULLY. This endorsement modifies insurance policy under the following:
LIABILITY COVERAGE PART:
Schedule
Name of Person or Organization:
City of San Juan Capistrano
Public Works Director
32400 Paseo Adelanto
San Juan Capistrano, CA 92675
SECTION II - WHO IS AN INSURED is amended to include as an insured the
person or organization shown in the Schedule, but only with respect to liability
arising out of "your work" for that insured by or for you.
The City of San Juan Capistrano is named as an additional insured as
respects general liability for claims arising from the operations of
the named insured.
PRIMARY INSURANCE:
IT IS UNDERSTOOD AND AGREED THAT THIS INSURANCE IS PRIMARY
AND ANY OTHER INSURANCE MAINTAINED BY THE ADDITIONAL INSURED
SHALL BE EXCESS ONLY AND NOT CONTRIBUTING WITH THIS
INSURANCE.
CL/BF 22 40 03 95
9/11/03 1:25 PM
1-510-452-2193
•
19494931053
•
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
005
This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different
date is indicated below.
(The following "attaching clause" needs to be completed only when this endorsement is issued subsequent to preparation of the policy.)
This endorsement forms a pan of Policy No. WVA7724714
Issuedto: Alexander Engineers, Inc.
By: St Paul Fire & Marine
Premium (if any) TBD
We have a right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our
right against the person or organization named in the Schedule. (This agreement applies only to the extent that you
perform work under a written contract that requires you to obtain this agreement from us).
You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work
described in the Schedule.
The additional premium for this endorsement shall be 2-5% of the California workers compensation premium otherwise
due on such remuneration.
Schedule
Person or Organization
City of San Juan Capistrano
Public Works Director
32400 Paseo Adelanto
San Juan Capistrano, CA 92675
wr na rin na CmintorcinnPA by
Job Description
y}j"- CL. -yZoda,
9/11/03 11:05 AM 1-510-452-2193
19494931053 002
Al CVACMMI
ACORn_. CERTIFICA OF LIABILITY INS NCE
02/;o,� °'"Y'
PRODUCER
Dealey, Renton & Associates
199 Los Robles Avenue#540
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
Pasadena, Ca 91101
626-894-3070
INSURED
INSURERA: United States Fidel & Guaranty
Alexander Engineers, Inc.
INSURER B: St Paul Fire & Marine
502 W. Alosta Avenue #17
NsuRER cGreat American Assurance Co.
Glendora, CA 91740
NMURER D:
INSURER E:
L
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSFANDIN
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED O
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUC
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
NSRTYPE
POLICY EFFECTIVE
POLICY EXPIRATION
LIMITS
OF INSURANCE
POLICY NUMBER
YY
M D
A
GENERAL LIABILITY
BKO1226262
10/16/02
10/16/03
EACH OCCURRENCE E1,000,000
FIRE DAMAGE (Any n -F— £1000000
X COMMERCIALGBNERALLIABILITY
MED RXP (An one p,n ) $10000
CLAIMS MAER Fx—] TCCUR
PERSONAL&ADVINJURY t1 000000
GENERAL AGGREGATE s2,000,000
GEN'LAGOREGATE
LIMITAPPLIBS PER:
PRODUCTS-COMPIOPAGC, $2000000
POLICY
PSO LOC
A
AUTOMOBILE
LIABILITY
BKO1226262
10/16102
10/16/03
CDMBINED SINGLE LIMIT
$1,000,000
ANY AUTO
ALL OWNED AUTOS
BODILY INJURY
$
(P¢Persory
SCHEDULED AUTOS
EODILY INJURY $
X
HIRED AUTOS
X
/F<r accirnt)
NONOWNED AUTOS
PR,IPRRTY DAMAGE t
(Per uciaenn
GARAGE LIABILITY
AUTOONLY RAACCIDBNT $
CPHERTHAN PA ACS $
ANYAUTO
AUTO,-NLY: ACO $
EXCESS LIABILITY
EACH OCCURRRNCB $ _
AGOREGATE S
OCCUR FICLAIMSMACE
$
DEDUCTIBLE
RHTENTION S$
B
WORKERS COMPENSATION AND
WVA
09/01/03
09/01,04
X WC ST PIT �1'H-
R.L. PATH. ACCIDENT $1.000,000
B
EMPLOYERS' LIABILITY
H.L. DI$EA� -BA EMPLOY88 t1 000000
E.L. DISEASE -POLICY LI MIT £1000000
C
OTHER Professional
EDN320854703
10/16/02
10/16/03
$1,000,000 per claim
lability
$1,000,000 annl aggr.
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
"The Insurer's policy payment obligations are backed by a cut -through to National
Indemnity Company, an A++ rated Berkshire Hathaway subsidiary. Please see the attached
document confirming this arrangement.
The City of San Juan Capistrano Is named as an additional Insured as
(See Attached Descriptions)
City of San Juan Capistrano
Public Works Director
32400 Paseo Adelanto
San Juan Capistrano, CA 92675
SHOULD ANYOFTHEABOW DESCRIBED POLIOS BE CANCELLED BEFORETH E EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL-XXXX 000MMAII'3D_ DAYS WRBTEN
NOTICE TOTHE C'ERTIFIGATE HOLDER N.AMEDTOTHE LEFT. B
9/11/03 11:05 AM 1-510-452-2193 19494931053 003
DES PTIONS (Continued from P 1)
respects general liability for claims arising from the operations of the
named Insured.
9/11/03 11:05 AM
Policy Number
1-510-452-2193
Pi
BKO1226262
Owners Lessees or Contractors (Form B)
ADDITIbNAL INSURED
Change(s) Effective: 02/10/03
19494931053
•
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT
CAREFULLY. This endorsement modifies insurance policy under the following:
LIABILITY COVERAGE PART:
Schedule
Name of Person or Organization:
City of San Juan Capistrano
Public Works Director
32400 Paseo Adelanto
San Juan Capistrano, CA 92675
SECTION II - WHO IS AN INSURED is amended to include as an insured the
person or organization shown in the Schedule, but only with respect to liability
arising out of "your work" for that insured by or for you.
CL/BF 22 40 03 95
004
9/11/03 11:05 AM
Policy Number
1-510-452-2193
u
BKO1226262
Owners Lessees or Contractors (Form B)
ADDITIbNAL INSURED
Change(s) Effective: 02/10/03
19494931053
•
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT
CAREFULLY. This endorsement modifies insurance policy under the following:
LIABILITY COVERAGE PART:
Schedule
Name of Person or Organization:
City of San Juan Capistrano
Public Works Director
32400 Paseo Adelanto
San Juan Capistrano, CA 92675
SECTION II - WHO IS AN INSURED is amended to include as an insured the
person or organization shown in the Schedule, but only with respect to liability
arising out of "your work" for that insured by or for you.
005
The City of San Juan Capistrano is named as an additional insured as
respects general liability for claims arising from the operations of
the named insured.
PRIMARY INSURANCE:
IT IS UNDERSTOOD AND AGREED THAT THIS INSURANCE IS PRIMARY
AND ANY OTHER INSURANCE MAINTAINED BY THE ADDITIONAL INSURED
SHALL BE EXCESS ONLY AND NOT CONTRIBUTING WITH THIS
INSURANCE.
CL/BF 22 40 03 95
9/11/03 11:05 AM 1-510-452-2193 19494931053 006
• 0
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different
date is indicated below.
(The following "attaching clause" needs to be completed only when this endorsement is issued subsequent to preparation of the policy.)
This endorsement forms a part of Policy No. WVA
Issuedto: Alexander Engineers, Inc.
By: St Paul Fire & Marine
Premium (if any) TBD
We have a right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our
right against the person or organization named in the Schedule. (This agreement applies only to the extent that you
perform work under a written contract that requires you to obtain this agreement from us).
You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work
described in the Schedule.
The additional premium for this endorsement shall be 2-5% of the California workers compensation premium otherwise
due on such remuneration.
Schedule
Person or Organization
City of San Juan Capistrano
Public Works Director
32400 Paseo Adelanto
San Juan Capistrano, CA 92675
Wr na av na rmmtaminnwl by
Job Description
Jan -28-03 08:14A Alexander Engineers Inc 626 963 9386 P.03
1/24/03 4:25 PM 1-510-45Z-"3 1act3aa3asaa & Uvc
AI CVe
MA& CERTIFICATE OF LIABILITY INSURANCE
o;R;�;""'
rRGaJCER
De*ley,ROMon6Ae*oclelee
THIS CERTIFICATE IS ISSUED AS A MATTER OF TNFORM411ON
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND U
600 S. Links Avenue 6306
ALTER THE COVERAGE AFFORDED BV THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
Pasadena, Ca silos
626644-3070
INM,aED
INWW A: Unfted State* FNe91y i Guaranty
Alexander Engineers, Inc.
INaJRER w American Mntorlsb hra. Co.
SM W. Aloafa Avenue 017
1NsvRERc Gaal American Asauranee Co.
Glendora, CA 91740
Ms.IReR D.
mureRR E
X tLMMNNCL4.r,iRwil" I.1.11.IY
CLAIMS MADII 7 iF:<:IIR
City of San Juan Capistrano
Atin: Peer Salgado
32400 Pee" Adelento
San Juan Ceplelra", CA 92676
ACORD 25-S 17IV7'I 1 of I 11Se3SS211H60303
'TReAeoveDeacl®ep raR-.ce el: eAYEewep eerGNETN EexvIMT1O1
•, Txe usulxc InauRea W1Liaaxa�MAl13(L�pAYf wamex
C¢R AT[Np.DENNwMxpl'GTNc Y:R. BIOOa0ee1m0 MMm
MAF 0 ACORD CORPORATION IVBR
THEcPOLICTF.S OF DSSURANOI LIxrEO BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOtB FOR FEE POIIEN FERIOD INDICATED, NOTWTTHSI'ANUIN
ANY RBQUIREmeNT, TERM UR CONDITION OP ANY CONTRACT OR OTHER DOMfIZNT WITH RESPECT TO WHICH THIS C'YR'nYICA'IL MAlBE 1SSUPD 0
MAY PPATAIN. THP. TNSURANC B AFFORDED BY THE POLIOS OESCI BED HEREIN IS SCHISM TO ALL THE TERMS, PYCT.OSIONS AND CONDITIONS OF SUCt
POLICIES. AGGREGATE LDIJ S SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
MS
TYPE W INSUMNM
PMICT NUMB
POIACT ETPECI'IV'E
C4 EA RA IIXI
IJMITe
A
GENEMI.LIAMI.ITY
SK01226262
io/16JD2
10/I6,93
EALII C•1:URRFM.Y. t
MRS UAMAGRi —Are! tl0100
•N.'
X tLMMNNCL4.r,iRwil" I.1.11.IY
CLAIMS MADII 7 iF:<:IIR
1,12D UNI, t MOW
iERSCNAtk AR'INJVRY S1.000AW
4BN'BRALN:GR9:AYB s2,000AW
OBN1NJGREOAIU
LIMO' AYI•LIBS
I K:
Pkr t'l$ �v'•MVM AC:• [2000
-
r:n.IR M
Nli
A
AMWOKILRIJASILITT
ANY.VltO
BKO1226262
10/10RBS/02
eYfa
10/16,93
SAdEINEp ANry6LIMR 11,000,000
R.[ w'clai!
BGDIL.Y INJURY
Ye* pO
ALL CMNIO A'RrN
N]IICIPILPU AM, G
&MILY INAMY
Rn neiln[, t
X
X
NIRRG ADT:'S
Nr•H+:wNEG AUT•JS
rRifERTYi•AMnGP. [
GARAGE
LIANUTP
AUFOGNI.Y- KA AMDP.NI t
M1ERT).N L•A A'JC I
ANY NII '^.
ALg0ow LY'. AW 1
ERCtOLLABILITY
DAGI D$URRP.N:'P. t
AGGREGATE [
OCCUR �ClnIM!'11AM
f
1
D1101j1=O1A
1
RM11NII0N t
B
WCR%EMS L'OMP[NGTIW AND
7CW33763003
o"IM2
09/01,93
X WCSTATU. c7H.
EL.LICr1ACJOQM 11000
B
EMM.OER!" LIABILITY
E.L.DISRAIM EABAIPLIYUH 11000000
E.L.DWAV. P•?LIR LIMB 10WAW
C
OTNiER Protaallonal
EON320854703
10/1102
10/1610.1
S1,00DAW per claim
Willy
-
$1,000,000 snnl sggr.
mcwrr10N gCXEAATION1yLOCATIGNE/VUIICLP$'IXCLUBIONE ADDED BY PAVDCREEMGNT9PF.CIwL niWIB10NE
The CHy of San Juan Caplstrano Is named an an addMbnal Insured as
respects genera111s69Hyfor claims arising from the operations of the
named Insured.
City of San Juan Capistrano
Atin: Peer Salgado
32400 Pee" Adelento
San Juan Ceplelra", CA 92676
ACORD 25-S 17IV7'I 1 of I 11Se3SS211H60303
'TReAeoveDeacl®ep raR-.ce el: eAYEewep eerGNETN EexvIMT1O1
•, Txe usulxc InauRea W1Liaaxa�MAl13(L�pAYf wamex
C¢R AT[Np.DENNwMxpl'GTNc Y:R. BIOOa0ee1m0 MMm
MAF 0 ACORD CORPORATION IVBR
Jan -28-03 08:15A Alexander Engineers Inc 626 963 9386 P.04
1/24703 4:Z5 PM 1-510-45Z 3 1ti'LCi`.1E3"J'J-7tlt3 • UVU
Policy Number: BK02226262
Owners Lessees or Contractors (Form B)
ADDITIbNAL INSURED
Change(s) Effective: 01/24/03
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT
CAREFULLY, This endorsement modifies insurance policy under the following:
LIABILITY COVERAGE PART:
Schedule
Name of Person or Organization:
City of San Juan Capistrano
Attn: Peter Salgado
32400 Paseo Adelanto
San Juan Capistrano, CA 92675
SECTION II - WHO IS AN INSURED is amended to include as an insured the
person or organization shown in the Schedule, but only with respect to liability
arising out of 'your work" for that insured by or for you,
CL/BF 22 40 03 95
Jan -28-03 08:15A Alexander Engineers Inc 626 963 9386 P.05
1/Zqf" 4:Z0 PPI I-D1u-4DZW:S • VV4
Policy Number: BRO1226262
Owners Lessees or Contractors (Form B)
ADDITIbNAL INSURED
Change(s) Effective: 01/24/03
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT
CAREFULLY. This endorsement modifies insurance policy under the following:
LiABiLITY COVERAGE PART:
Schedule
Name of Person or Organization:
City of San Juan Capistrano
Attn: Peter Salgado
32400 Paseo Adelanto
San Juan Capistrano, CA 92675
SECTION II - WHO IS AN INSURED is amended to include as an insured the
person or organization shown in the Schedule, but only with respect to liability
arising out of "your work' for that insured by or for you.
The City of San Juan Capistrano is named as an additional insured as
respects general liability for claims arising from the operations of
the named insured.
PRIMARY INSURANCE:
IT IS UNDERSTOOD AND AGREED THAT THIS INSURANCE IS PRIMARY
AND ANY OTHER INSURANCE MAINTAINED BY THE ADDITIONAL INSURED
SHALL BE EXCESS ONLY AND NOT CONTRIBUTING WITH THIS
INSURANCE.
CL/BF 22 40 03 95
Jan -28-D3 O8:15A Alexander Engineers Inc 626 963 9386 P.O6
Itzq/03 4:Z5 pM 1"blu-40C r 11:5408aaaaao • vva
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different
date is indicated below.
(The loeowhg "altaN hg deuce" needs to be OOr V1eleo only when this endorsement K Issued oubcequent to proMatifn of Ere Pdky.)
This endorsement forms a part of Policy No. 7CW33763003
issuedto: Alexander Engineers, Inc.
By: American Motorists Ins. Co.
Premium (if any) TBD_
Werlrave a right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our
right against the person or organization named in the Schedule. (This agreement applies only to the extent that you
perform work under a written contract that requires you to obtain this agreement from us),
You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work
described in the Schedule.
The additional premium for this endorsement shall be 2-5% of the California workers compensation premium otherwise
due on such remuneration.
Schedule
Person or Organization Job Description
city of San Juan Capistrano
Attn: Peter Salgado
32400 Paseo Adelanto
San Juan Capistrano, CA 92675
WC 04 03 06 - Countersigned by
(Ed. 4.84) Authorized Representative