1999-0125_CALIFORNIA TRAFFIC MAINTENANCE_Workers' Comp Insurance •
;� „40,0i:4.,'''''';-;e 4-*''''''
;`' i, }t'Z g. r:..4 T w } �.}_ `.,. Lr ,'I 'r 4 - 44 :.,•�•-.`v. k ,q ‘11
V �Y�'�'s.� .'r 'L`� .k'T�: �`•]'1' ..„1.;,,,,..411, � � p� �I•f. t. .f'� :O �^�"•
N yy��T� •..5!!
i"' «'SG ,J;2 r<. +.. 'T '♦ '� r `K { „,,:i4,:,--,-1,:,,,t1.., k , ' �♦ 'S . r,� r - ♦ R� i
{ .',I. '* iy . N r"{.-{ t - ' r , ,r' !x ;j t, R x le t Mt i rlP ,;.., ,,
a
'5,,,:,),"'' '.•,:44.47-.'. 4 S� C.l'.X ,5'-N'L t... t ?1. .� ..p K- t, R,,)r i,, t. �:.1 , ,r .�, ,
41
'i ,” :„. „'RR'' "`i' .s -.,'. +� t-"k' "'',1,,,,'„::.1*-..-
?`,+Y' r tY f Y r7
STATE P.O. BOX 420807, SAN FRANCISCO, CA 94142-0807 S ++��', '` ' ° , "-
COMPENSATION f.,"4.(1,';''.1.'... '4` t :':'`i'''',.:-..:§7:: :.,...%
: tj .,. `n`< �r •1
r 1 N S U R A N C E ' •�!dk`!4.?RW ".‘°'rf:' .'-M'' , d'"i '"- •, `�' ? s' ,f,', .' `'xf,'4yt`�'5"`....*t ,',,,V;.,,,„:41:',.`,,,,.''': ^ '}, ' ,.,,;sS,?lr :'5
FUND
O CERTIFICATE OF WORKERS' COMPENSATION INSURANCE, �', ''"� `" "' '�`�' '-..4,...,,,,,
"���-,,,t,,, .,.„;
�.�'
JANUARY 25, 1999 MFr � POLICY NUMBER: 046-99 UNIT 0007629
' CERTIFICATE EXPIRES: 1-1-00
• ,
* CITY OF SAN CAPISTRANO ,��`' t1, * fi;, ` ��# ;' '� 'r.2 ;�..r�R :�� 4 �a
r, ATTN: CITY CLERK'S OFFICE ., , i,; , , -del
ADELANTO CA 92675 r��, k >K • JOB: PAVEMENT MARKING MA I NT �r;• ..:• , t "
-400 FASEO .,•
t.. `y . CONTRACT P.O. #15582 ° �;'.,',,,,f.;,_;''.4``, `
U'? K'5 . "''`f » l` 'i445 > " ' -"Votqtte`':-4'j. ,",z-,•.e + 'ff r i" .1
al
This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California
iInsurance Commissioner to the employer named below for the policy period indicated. _
x This policy is not subject to cancellation by the Fund except upon ten days'advance written notice to the employer. " ,.,r,,,..;74,:,
We will also give you TEN days'advance notice should this policy be cancelled prior to its normal expiration. r, '°t'., �'; .fi�'.;4
0...:**3+ Y,,�* `40+4'4 " ` 1' `�, *-Z, ,s -'hili "P. ':�iA0,-,•, , -.-zwre �. 1 ,+ +w !,,;f.?._ _.:,4; Irl ;�.-.,_rix .
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the ,
I* policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other document with
9 respect to which this certificate of insurance may be issued or may pertain, the insurance afforded by the policies' r -"
described •herein is subject to all the terms, exclusions and conditions of such policies s z,>b x ,{x b ,
• y u
�.//''�t� t .T.` 'P.rf adtT..::>• :.44R �+Y/ Y.4 {jt•w ,.H Are-
r a{W���
iiite-.11;7' ''''''' '- ezj.1, e,ef. t. t:-,. :: . , ,:, ‘ ,,:,,t1.....;!
4:
., ..
I ,„... ..,,„
a ,.....,,,
AUTHORIZED REPRESENTATIVE PRESIDENT }, � a#, 4.0-i....,
�K :,f es
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000^,000 PER OCCURRENCE.14:$:`,.:".:', '`
, F,'� y` • rte. "'•C 'w ,y.{R r'9 a °:s r�..ie.+,"1`r^vra fi'; •} .::,Z„ ` , ,t l' 9G .i ^� �'a '`�4";'' v 4. { �'q
,.4„'^y,R 1 �, „„.„,„,.,„/„.r,„-,4`�r ,,,,„„,„.f.,:,.�,.,,,:,,,,,,,,„,,,,,,,,,..,..„5,.,,,„,,,,,,,,,`zf.aa 4P4:,‘•77-14: Fr ” •3,1•, • �.,sdE �y r„,go*��' .3,.„ -r t '" "fi,t,..„?.,.„ ,..,,,.,
tfi S',,.1e
'` .p '�t4,4 4 P try,- r---.-4,,,,44.',4-40:4i,--A r�r .,..,-,-:,,,,•.„:
,, x{ ' ( ' ,,,,f, tvY 4 r ' r ii 6 „:,
n" 'r. r „M )„.< i3.^':rr"k t { i✓r.v Sifi.� `1 . 6 ” r `s'r'-'ri l"....y.-ti-4,--4.-..714
,.�-,,t,"":7,-.;•.;;;:t.:...,', �Yr+v�K y,.•+.: i ' t;1,
t ,+ `3-<. `!{ir'T e i i .._,i t<r r 114 } '- *, .. ►i s.tx4 ;'” . " r r ; ,e r,,,, ice,:
w -- 4.- ";!.,!,,,,,...3-t--,,,, -A, t!•+. x� ▪. '"- ,,,,,,-.A, 9l . ,,y _, ,, t ! _, -gin a x +' J"I{r. +
.,.,:L•yl,�t�-� ^� t r,. .f"T µ:{s {.'f w;t ir,. . ' -:: .�� ,`�' *�.+. ,�;.:. �� 0. 'S�,�4:��:,,'; '�� �.7 ..,4,1',:.,:,4 * =,'�
, ....... rn
« ♦ {vim crS + + t44,•4,-.;:',.:-•.-,- + w r• C7
7 ---;..'•':''.
..` r "iz' •'�, `' •t..4
.r "• •}„ .,''},t', ''',..1p***,,..;*..... i ,e, ,�"Yt.' --11.'71`..-;*:-F' .• a4-s,-y� .---,---
s
!t'
•
.....,.,
'C=
,tv'i 'r i` ', siss r."•-4.4-,:,,..fp ° ?,. "' . i _
C' ,i.' i'41.,
1,,' ' ',, Jy , '1"t, ,• e r �` . .' . ,.4 , tc4 r '' , ` .tv, {,s .; R orb y, y t;;;,te,isi:,.::: ::.
. fw' itt
,,,,,h't. J
Y r~ {« ., .1•••7:;,••..,..,,,,.. .%.,',,:::,� ,� `^eat " ' 'fit s ' ,,. '.',,t* .. ,�v,• *' .,roi
, r'.••••'
:'''''••:1::.
' _ 'f �a, } �.1" r�J cc A....,!:;;;;X:!;; s .� •' "y. ,r , ,s+9 V. ...,t
�kF p ',•-r, r ,u tea e-.
iu •• . ' EMPLOYER . Q SAc s ! s .y ,. .�r f
4 ,: � t:,• ht t,i r ' w_ �rt,
412.
,........:;;c71';‘''...''.';,..,, T W iP ,�5, tii
J++p�
„kP y,r " ��}^�� t',?? n ems' G.�Y '..14....1-','''''..!:::'`...::'''''';,:i.
2l ✓r: ^t �'./ C /) : ]y.' y � /, �f(r
Y�,''' '2,! .. t j�> '4a.M 2, ,t S [ ,�V V 1 X Y.^ I'd !_,* ti 4 1 "S� 1 ../�':5�� r,
? v
*" 4't,.,�; ,: +=."y?" ,. ;. "�* ':r s� 4.;::;!...''...'-„R..•"rM `-. g zr�. - ?q. '*.fit +'�{i{}
1' (y� � Y e $ XX r a« it
• GILBERT APODACA ► t,-,, ,ii� } ,# t .'r. ; xr ..a r�
�t � ��. ..� 1 4^��� ve tt •t'Ic� l 1'JY,F'L
1. DBA: CALIFORNIA TRAFFIC MAINTENANCE , ' 3 ' ,
kir1751 N CALIFORNIA STREET �. x, ;-,` �;.'p`l`'is ••. +'o. "'�A .-7,,, ` -+ t` .,
* BURBANK CA 91505 P yr v� � '4' "`,4**,', =,;r ,*T'}1,, �'� R ' i� '
c__xn7
L-
THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND SCIF 10262(REV.3-95)