1993-1021_C.B. ELECTRIC_Workers' Comp Certificate OCT 21 '93 11:19 SCIF SG-PIC/CMTS P.z2
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STATE P.O.BOX 420807, SAN FRANCISCO,CA 94142-)807 6 i
COMPSHSATION Oi �/`
INSAJIPtAINCE
FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE •
OCTOBER 21 , 1993 PoLICYNuMBER: 1362813 - 93
CERTIFICATE EXPIRES: 1 0-1 -94
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CITY OF SAN "JUAN CAPISTRANO
ATTENTION: NANCY BARNEY/PUBLIC LANDS & FACILiTIES
32400 PASEO ADELANTO
SAN JUAN CAPISTRANO , CA 92675 JOB : 341641
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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 rtarned below for the policy period indicated
This policy is not subiect 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 subiect to all the terms,exclusions and conditions of such policies.
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PRESIDENT
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BROWN , CHARLES D. AND BROWN , SHARON L .
DBA: c B ELECTRIC - .
114 AVENUE SIERRA
SAN CLEMENTE , CA 92672
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SCIF 10262(REV.10.86)
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STATE P.O. BOX 420807, SAN FRANCISCO, CA 94142-0807
COMPENSATION
INSURANCE
FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
OCTOBER 21 , 1993 POLICY NUMBER: 1362813 - 93
CERTIFICATE EXPIRES: 10-1 -94
1 •
CITY OF SAN JUAN CAPISTRANO
ATTENTION : NANCY BARNEY/PUBLIC LANDS & FACILITIES
32400 PASEO ADELANTO
SAN JUAN CAPISTRANO , CA 92675 JOB : 341641 •
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.
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PRESIDENT
EMPLOYER
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BROWN , CHARLES D . AND BROWN , SHARON L .
DBA : C B ELECTRIC
114 AVENUE SIERRA ,OCT 2 21993
SAN CLEMENTE , CA 92672
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