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RE All operators of the named Inal,rad for the certificate holder I�ct4
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V EXMLATtaIi DATE THEEZOW,TrL eiaveuj CO*RANY WILL aeleseeisame
''' MAIL 4n DA Ya WKrrYkN NOTICE To TI t ClarIrICA Tr W.W.I IfAMID TO TTlT.
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Attn Katny Gronelr " . . ,. -
32400 PaC Ad.lant0 .Af— -- 1,1, Z7 Gds-
Sari Juan Capistrano, CA 92675 r AUTI(aw(zLDazlRntxrATr.z j�J//,��� +{,�jt..�5lr�„# r';�+ C��
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i39 29/1997 12: 16 714-6?2-5077 r'4J J3 PQaE 03
POLICY NUMBER C013tK0754 COMMERCIAL GENERAL LIABILITY
CG201011 85
Paulus Engineering. Inc
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED OWNERS, LESSEES OR
CONTRACTORS (FORM B)
Ttris endorsement modifies insurance provided under the following.
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization:
Cay of San Juan Caplstreno RE: All cperetons of the named Insured for trio
32400 Paseo Adetento certificate holder
San Juan Capistrano, CA 92875-36C3
(If no entry appears above, information required to complete this endorsement writ be shown in the
Declarations as applicable to this endorsement,)
WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization
shown in the Schedule, but only wltn respect to liability ars ng out of "your work' for that insured
by or for you
CG 20 1011 85 Copyright, Insurance Services Office, Inc , 1984