1997-0819_PETAR ARTUKOVICH CONSTRUCTION_Certificate of Insurance •
STATE P.O. BOX 420807, SAN FRANCISCO, CA 94142-0807
COMPENSATION pIO•✓v
INSURANCE
FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
AUGUST 19 , 1997 POLICY NUMBER: 1446762 - 97
CERTIFICATE EXPIRES: 9-1-9 8
CITY OF SAN JUAN CAPISTRANO (,):;%
CITY CLERKS OFFICE C—
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32400 PASEO ADELANITO .
SAN JUAN CAPISTRANO, CA 92675 JOB : INSURANCE VERIFICATION
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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 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.
AUTHORIZED REPRESENTATIVE PRESIDENT
EMPLOYER ' S LIABILITY LIMIT INCLUDING DEFENSE COSTS : 41 , 000, 000 PER OCCURRENCE
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EMPLOYER
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PETAR ARTUKOVICH CONSTRUCTION CO . , INC .
8243 SERANATA DR
WHITTIER CA 90603
• THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND SCIF 10262(REV.3-95)
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DRUG USE ' MEMBERS OF THE CITY COUNCIL
IS s OLLENE CAMPBELL
JOHN OHN GREINER
I 4 IREDRPORRIED WYATT HART
• ESIRIIISNED 1961 GIL JONES
1776 I DAVID M.SWERDLIN
•
CITY MANAGER
• • GEORGE SCARBOROUGH
August 14, 1997
Petar Artukovich Construction Company
8243 Seranata Drive
Whittier, California 90603
Re: Renewal of Workers Compensation Certificate of Insurance (Marbella Gravity Sewer)
Gentlemen:
The Workers' Compensation Certificate of Insurance, regarding the above-referenced project, is due
to expire on September 1, 1997. 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 September 12, 1997.
If you have any questions, please contact me at (714) 443-6310.
Thank you for your cooperation.
Very truly yours,
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Dawn M. Schanderl
Deputy City Clerk
• c: Cheryl Johnson, City Clerk
Brian Perry, Senior Civil Engineer
32400 PASEO ADELANTO, SAN JUAN CAPISTRANO, CALIFORNIA 92675 • (714) 493-1171