1988-0602_BLAIR PAVING, INC_Workers' Comp Insurance4 0
STATE P.O. BOX 807, SAN FRANCISCO, CALIFORNIA 94101-0807
COMâ–ºSNSATION
IN a U RANO !
FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
JUNE 2, 1988 POLICYNUMBER: 0732704 - 88
CERTIFICATE EXPIRES: 2-28-89
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CITY OF SAN JUAN CAPISTRANO
BUILDING & SAFETY DEPARTMENT
32400 PASEO ADELANTO
SAN JUAN CAPISTRANO
CALIFORNIA 92675
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JOB: SAN JUAN CREEK ROAD
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.
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This policy is not subject to cancellation by the Fund except upon t"ays' advance written notice to the employer.
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We will also give you T$Ndays' 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.
PRESIDENT
ENDORSEMENT 82065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE
02/28/88 IS ATTACHED TO AND FORMS A PART OF THIS POLICY.
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EMPLOYER
BLAIR PAVING, INC.
4226 EAST LA PALMA
ANAHEIM
CALIFORNIA 92807
SCIF 10262 (REV. 10-66) OLD 262A
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EMPLOYER
BLAIR PAVING, INC.
4226 EAST LA PALMA
ANAHEIM
CALIFORNIA 92807
SCIF 10262 (REV. 10-66) OLD 262A