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1995-1031_EMPIRE PIPE CLEANING & EQUIPMENT_Certificate of Insurance A1.111a1. CERTIFIC IE OF INSURANCE ghei D 10/31/95 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION BOSWELL INSURANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Agents & Brokers, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P.O. Box 4648 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Mission Viejo C\ 92690 COMPANIES AFFORDING COVERAGE Joe A. Boswell COMPANY 714-855-0430 A Golden Eagle Insurance Company INSURED COMPANY B Empire Pipe Cleaning & COMPANY Equipment, Inc. P.O. Box 8035 COMPANY Anaheim CA 92812 COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE(MM/DD/YY) DATE(MM/DD/YY) GENERAL LIABILITY GENERAL AGGREGATE $ COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG $ CLAIMS MADE OCCUR PERSONAL&ADV INJURY $ OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE I. FIRE DAMAGE(Any one fire) $ MED EXP(Any one person) $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM _$ A WORKERS COMPENSATION AND X STATUTORY LIMITS EMPLOYERS'LIABILITY EACH ACCIDENT $ 1,000,000 THE PROPRIETOR/ X INCL NWC33606203 11/01/95 11/01/96 DISEASE-POLICY LIMIT $ 1,000,000 PARTNERS/EXECUTIVE OFFICERS ARE: EXCL DISEASE-EACH EMPLOYEE $ 1,000,000 OTHER Z b .mc DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS C CERTIFICATE ISSUED TO UPDATE WORKERS' COMPENSATION COVERAGE ONLYc n — 73 *10 days for non-payment of premium or non-reporting of payroll ,--4,- " r‘..) f'I CERTIFICATE HOLDER CANCELLATION` ' �`� SANJU-4 SHOULD ANY OF THE ABOVE DESCRIBED POLIO BE,CANCEE)BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COM'ANY WILL MAIL. City of San Juan Capistrano *30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDEIMED TO THE LEFT, Comminity Redevelopment Agency 32400 Paseo Adel anto UCH NOTICE SHALL IMPOSE-NO OBLIGATION OR LIABILITY San Juan Capistrano CA 92675 AUTHORIZED REPRESENTATIVE'" Joe A. Boswell , –70C C _ �o� ur:-C�t� ACORD 25-S(3/93) 5/ ACORD COR'PQRATION 1993 w 41." _`f Y .�. . S .i 4 t,-,, i;{ .r v- . • ` .„'* y • 't•S' - �i rpt' ',!4[7. 4 y�, - + t . '. 4 ` �' t �j'�r • k" '� / .y�,,��,,�:.. *..., .0. ..i'i�•, . '�.`�P,l•.. ate .mac. ., • ,.S •,t, " . 1 •, • !', 1 'i- yam? «;.t . . y •'.b -....,„4-...N, a t IYIY7Y(- .. ,.•., -• . , •„ , ., •,4•- i.....," .., h. ;•,.c: r", •,..4k, • a,y��"y�,, ra t° ti • S► . -SS•J .. i iva a •' er w t�� e A?`r. - • •..7 • • . -A r.1� ,-Wb•. ..'. �.•'1M -•S'-tet`• •`r.w.. .z. . e. , . - Y w `11 '., Y•... <_ •j. s 4. ♦ �t } s.. _ 9,, 1 4 it +4 .. e • wf1$ jy ..-.I - r` j 1 ,---, .4:4:S+ v Y_,,,,,,t•- ° `^r�,� =cew.ifw.'arsr� fax ..1446:*. s.._a.. a_ ../. ( '.,� .~ -.-' • , ,i Aft• • r • .1 < ... ,4„ r•' stvyithh * kj_ s t . . AI:III'.11. CERTIFIC CE OF INSURANCE � ? Diiioii75 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION BOSWELL INSURANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Agents & Bracers, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P.O. Box 4648 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Mission Viejo CA 92690 COMPANIES AFFORDING COVERAGE Joe A. Boswell COMPANY714-855-043430 AGolden Eagle Insurance Company INSURED COMPANY B Empire Pipe Cleaning & COMPANY Equipment, Inc. P.O. Box 8035 COMPANY Anaheim CA 92812 D COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE(MM/DD/YY) DATE(MM/DD/YY) GENERAL LIABILITY GENERAL AGGREGATE $ COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG $ CLAIMS MADE OCCUR PERSONAL&ADV INJURY $ OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ FIRE DAMAGE(Any one fire) $ MED EXP(Any one person) $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM $ A WORKERS COMPENSATION AND X STATUTORY LIMITS EMPLOYERS'LIABILITY EACH ACCIDENT $ 1,000,000 THE PROPRIETOR/ X INCL NWC33606203 11/01/95 11/01/96 DISEASE-POLICY LIMIT $ 1,000,000 PARTNERS/EXECUTIVE — OFFICERS ARE: EXCL DISEASE-EACH EMPLOYEE $ 1,000,000 OTHER O rc4 IV ; i ri DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS -'<>—< n CERTIFICATE ISSUED TO UPDATE WORKERS' COMPENSATION COVERAGE ONLY rn :fi m r c? •C cnrn *10 days for non-payment of premium or non-reporting of payroll . -W1;) CERTIFICATE HOLDER CANCELLATION . c1� SANJU-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLWIYfEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL MAIL City of San Juan Capistrano *30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Attn: City Clerk 32400 Paseo Adel anto -•- CE SHALL IMPOSE N©-OBLEGATFON-ORtfA$tL-M" San Juan Capistrano, CA 92675 - • OENTSOR REPRESENTATIVES. AUTHORIZED REPRESENTA �] ��J;r � , Joe A. Boswell C C // \Y"�)QlL-y "ff=='jj((D//ll� ACORD 25-5(3/93) / ' ACORD CORPORATION 1993 i I IMEMBERS OF THE CITY COUNCIL COLLENE CAMPBELL ATT HART DRUG USE y I, GIL JONES IS fi" ,DCDaPDeerED • s1 ' ESIPILISHIO 1961 DCAVID SWERDLIN N NASH • l 1776 l'' CITY MANAGER. GEORGE SCARBOROUGH October 31, 1995 Empire Pipe Cleaning & Equipment Inc. P.O. Box 8035 Anaheim, California 92802 Re: Renewal of Workers' Compensation Certificate of Insurance (City Sanitary Sewer Line Maintenance) Gentlemen: The Workers' Compensation Certificate of Insurance, regarding the above-referenced service, is due to expire on November 1, 1995. In accordance with your agreement, the insurance certificate needs to be renewed for an additional period of one year. Please forward an updated certificate to the City of San Juan Capistrano, attention City Clerk's office, by November 16, 1995. If you have any questions, please contact me at (714) 443-6310. Thank you for your cooperation. Very truly yours, /0&0191)" 011,4/411At Dawn M. Schanderl Deputy City Clerk cc: Cheryl Johnson, City Clerk ' Nancy Barney, Administrative Assistant 32400 PASEO ADELANTO, SAN JUAN CAPISTRANO, CALIFORNIA 92675 • (714) 493-1171