1994-1026_C.B. ELECTRIC_Workers' Comp Insurance STATE P.O. BOX 420807, SAN FRANCISCO, CA 94142-0807 6er, ,30 ....
, COMPENSATION
r
r INSURANCE ',/, 3, , '45e, ."t"".2-4 ..,-
FUND .,..
, ‘
*3,11
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
OCTOBER 26 , 1994 POLICY NUMBER: 1362813 - 94
CERTIFICATE EXPIRES: 1 0-1 -95 ,to,i1
F
F
'..:' CITY OF SAN JUAN CAPISTRANO
4.7‘ BUILDING & SAFETY DEPARTMENT/ATTN : NANCY BARNEY
32400 PASEO ADELANTO
SAN JUAN CAPISTRANO , CA 92675 JOB : ALL OPERATIONS
EMPLOYEE=1
'----,k, L
This is to certify that we have issued a valid WorkersCompensation 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. 4'' ":: 4:1 ',,,,,',:'',,,,,,:",:`:,,I,,,e-1:tf,t,,,,7..,:.,-;:„.,,:g.-'
, 1, •"..$4,,,,V
jThis certificate Of'in'sur'ance 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. ..„1
PRESIDENT
... . . ,
ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE
10/26/94 IS ATTACHED TO AND FORMS A PART OF THIS POLICY .
NA1,IE OF ADDITIONAL INSURED : CITY OF SAN JUAN CAPISTRANO
•';' ,1,"‘'''''''',. ".: -''''''''' ', , .,' ' ' " , ' ,. , - .* , ' „ ,, - ,',' ,' '''',;`,,,,, '''','''''',',,`,'^.'".`!.',•''';',5,
kt.--
-4
r.,,i-,;?,..,''1' „, , , c_ r•-..)
- ''-''
-.• rn
,-.... (_)
4....) .-Z
EMPLOYER
-
CHARLES D . BROWN AND SHARON L . BROWN -
„. .
DBA : C .B . ELECTRIC
‘,.
...
114 AVE . SIERRA
SAN CLEMENTE , CA 92672
• THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND SCIF 10262(REV.5-94)