2007-65318GM180102 CITY OF ENCINITAS 3/17/08
Project Master Inquiry 07:37:35
Project . . W03161 leu hill hyd analysis
Position to . . . - - Starting: character (s)
Type options, press Enter.
1=Select
Opt Account number Budget Actual Balance
531-0000-215.40-00 0 500.00- 500.00
_ 531-0000-.374.10-00 0 .00 .00
531-5316-531.41-50 0 273.60 273 . 60-
Pre-encumb: .00 Encumb .00
2008 YTD: .00 Pending .00
Budg: .00 PTD: 226.40- Balance 226.40
F3=Exit F5=Refresh F9=Misc. info Fll=Proj-to-dt F12=Cancel F17=Subset
F18=Encumbrance detail F19=Project activity list
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GM180I02
CITY OF ENCINITAS
3117108
Project Master Inquiry
07:40:08
Project . .
W03160 Leucadia Hills insp dep
Position to . . .
Starting
character(s)
Type options, press
En
ter.
1=Select
Opt Account.number
Budget Actual
Balance
531-0000-215.40-
00
0 1,000.00-
1,000.00
_
531-5316-531.01-
00
0 1,612.44
1,612.44-
_
531-5316-531.11-
00
0 149.33
149.33-
531-5316-531.14-
00
0 160.07
160.07-
531-5316-531.17-
00
0 160.46
160.46-
531-5316-531.18-
00
0 4.47
4.47-
Pre
-encumb: .00 Encumb:
.00
20
08 YTD: 22.08 Pending-
.00
Budg:
.0
0 PTD: 1,086.77 Balance:
1,086.77-
F3=Exit F5=Refresh
F9=Misc. info Fll=Proj-to-dt F12=Cancel F17=Subset
F18=Encumbrance det
ail
F19=Project activity List
AN' Z.
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GM183I01
CITY OF ENCINITAS
3/17/08
Project Account Inquiry
07:38:19
Project . . . . . .
. : W03162 sec dep leu hills trask
Account number . .
. : 531-0000-218.00-00
Account description
. : DEPOSITS / SECURITY DEPOSIT
Position to . . . .
. . Fiscal year
Type options, press
Enter.
1=Select
opt Fiscal yr
Budget Ytd (Exclud encumb)
Balance
2005
.00 9,000.00-
9,000,00
2006
.00 .00
00
_
2007
.00 .00
.00
_
2008
.00 .00
:00
F11=Include encumbrances F12=Cancel
March 22, 2003
Michael Trask
3783 Vista Rim Place
Vista CA 92084
Phone (760) 583-8318
SAN DIEGUITO
505 S. VULCAN AVENUE
ENCINITAS, CALIFORNIA 92024-3633
(760) 633-2650
FAX (760) 633-2879
Re: Release of Cash Security Deposit for Water Improvements for Water Improvements
for a Subdivision Developed by Michael Trask., Agreement No. A-0067.
Summary of Accounts
Mr. Michael Trask:
Water improvements constructed by Michael A. Trask, for a project known as Leucadia Hills
located on the east side of Piraeus Street within the City of Encinitas, have been completed to
the satisfaction of the San Dieguito Water District.
Summary of Accounts:
W03-160 Inspection Deposit $1,000.00
Expense & O.H. $2.608.46
Account Balance: Deficit (Due to District) $1,608.46
W03-161 Hydraulic Analysis Deposit $500.00
Expense & O.H. $342.00
Account Balance: Refund Amount $158.00
W03-162 Security Deposit (Cash) $9,000.00
The District has determined that the Cash Deposit in the amount of $9,000.00 minus the
deficit of $1,608.46 plus the refund of $158.00 may be released at this time. Therefore, the
balance of accounts yields a refund in the amount of $7,549.54.
If you have any questions, please call me at (760) 633-2793.
Sincerely,
Blair A. Knoll, PE, PLS
Associate Civil Engineer
Enclosure
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When Recorded Mail To:
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District Clerk
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San Dieguito Water District
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.505 South. Vulcan Ave.
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Encinitas, CA 92024
For the Benefit of the District
DOCUMENT
G7CX UMENT NUMBER 2007-0065318
GF if S .J. ` P✓I ' H, t C_° UN 1 Y REC ORU-CR
=AN DIES (D%.GI.)N-I Y RE(-:O DER'S E FI~-,E
TIME 3:33 PM
NOTICE OF COMPLETION
6,42t., 6f6-
Assessor's Parcel Nos. 254-144-02 & 254-161-30 Agreement No. A-0067
.1. Michael Trask, on the 14"' day of November, 2003, entered into an "Improvement Agreement
Regarding Water Facilities with the San Dieguito Water District. The Agreement detailed the
requirements for the construction and installation of 1 new fire hydrant, new services and appurtenances,
within the subdivision known as Leucadia Hills in the City of Encinitas.
2. Said Covenant, including the plans and specifications for said improvements, is on file in the
Office of the Clerk of the Board of Directors.
3. Said improvements were completed by the owners and accepted by the San Dieguito Water
District Board of Directors on the 24th day of January, 2007.
4. Subdivision Bond No. 229162 from American Contractors Indemnity Company in the amount of
$27,000.00 may be released at this time.. The District will retain Cash in the amount of $9,000.00, which
shall be released at the end of the one-year warranty period.
5. All requirements of said Agreement have hereby been satisfied except for warranty.
6. Neither acceptance of said improvements by the Board of Directors nor this Notice constitute a
waiver of any defects in the work of the construction or installation of said improvements.
SAN DIEGUITO WATER DISTRICT
Victor Graves
Interim General Manager
VERIFICATION OF BOARD CLERK
I, the undersigned, say:
I am the Board Clerk of the San Dieguito Water District; the Board of Directors of said
District on January 24, 2007, accepted the above described work as completed and
ordered that a Notice of Completion be filed.
I declare under penalty of perjury that the forgoing is true and correct.
Executed on January 24, 2007, at Encinitas, California.
SAN DIEGUITO WATER DISTRICT
Deborah Cervone
Board Clerk
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Fire Line Capacity Fee
Plan Check Fee
Easement, Quitclaim, Encroachment Processing Fee
Water Availability Letter Fee
Plans & Specs Fees
Tanker Meter Rental Fee
Tanker Meter Installation Fee
Fire Flow Test Fee
DESCRIPTION OF DEPOSIT
WE ACCOUNT NO.
~I 531-0000-373-0500
1W
533-0000-373-0800
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531-0000-202-2400
3
531-0000-373-0501
MI
531-0000-373-0500
PW
531-0000-374-1000
MW
531-0000-374-9900
WL
531-0000-374-0200
MP
531-0000-374-0100
HR
531-0000-373-0600
TL
531-0000-374-0400
FF
531-0000-374-0900
Inspection Deposit - Project No. 3
000. 00''
JD
531-0000-215-4000
Fire Line Instl. Deposit - Project No.
JD
531-0000-215-4000
Security Deposit - Project No. GJ
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SD
531-0000-218-0000
Hydraulic Analysis Deposit - Project No.
WS
531-0000-215-4000
Fire Hydrant Instl. Deposit - Project No.
JD
531-0000-215-4000
Tanker Meter Deposit
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531-00007215-3000
Deposit on Water - Tanker Meter
TD
531-0000-215-3000
TOTAL
$ /D'Oco , cx.)
COMMENTS: 60x4gz 1'A /-/J C'C'-'5 S'
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GAdwd/eng/forms/feesht.doc
January 29, 2007
SAN DIEGUITO WATER DISTRICT
505 S. VULCAN AVENUE (760) 633-2650
ENCINITAS, CALIFORNIA 92024-3633 FAX (760) 633-2627
American Contractors Indemnity Company
9841 Airport Blvd., 9th Floor
Los Angeles, CA 90045
Re: Release of Improvement Bond No. 229162 Held for Security for Water
Improvements for a Developed by Michael A. Trask, Agreement No. A-0067.
To Whom It May Concern:
Water improvements constructed by Michael A. Trask for a project located on the east side
of Piraeus Street in the City of Encinitas, have been completed to the satisfaction of the
San Dieguito Water District. Therefore, the District has determined that Improvement
Bond No. 229162 in the amount of $27,000.00 may be released at this time.
If you have any questions, please call me at (760) 633-2862.
Sincerely,
4Gayy
Engineer I
San Dieguito Water District
Enclosure
Released to
Mailed
Print Name
Date
1/29/2007
o recycled paper
Bond # 229162
American Contractors Indemnity Company
9841 Airport Blvd., 9th Floor, Los Angeles, California 90045 N-0 9 0 8 9 7 3 5
POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS:
That American Contractors Indemnity Company of the State of California, a California corporation does hereby appoint,
Robert L. Hemme or David A. Hemme or Angelica Barnett or Timothy C. Baker
Its true and lawful Attorney(s)-in-Fact, with full authority to execute on its behalf bonds, undertakings, recognizances and other contracts
of indemnity and writings obligatory in the nature thereof, issued in the course of its business and to bind the Company thereby, in an
Amount not to exceed $ 100,000.00 This Power of Attorney shall expire without further action on
September 27, 2005.
This Power of Attorney is granted and is signed and sealed by facsimile under and by the authority of the following Resolution adopted
by the Board of Directors of AMERICAN CONTRACTORS INDEMNITY COMPANY at a meeting duly called and held on the 6th day
of December, 1990.
"RESOLVED that the Chief Executive Officer; President or any Vice President; Executive Vice President, Secretary or Assistant Secretary, shall have
the power and authority
1. To appoint Attorney(s)-in-Fact and to authorize them to `execute on behalf of the Company, and attache the seal of the Company thereto,
bonds and undertakings, contracts of indemnity and other writings obligatory to the nature thereof and,
2. To remove, at any time, any such Attorney-in fact and revoke the authority given.
RESOLVED FURTHER, that the signatures of such officers and the seal of the Company may be affixed to any such Power of Attorney or certificate
relating thereto by facsimile, and any such Power of Attorney or certificate bearing such facsimile signatures or facsimile seal shall be valid and
binding upon the Company and any such power so executed and certified by facsimile signatures and facsimile seal shall be valid and binding upon the
Company in the future with respect to any bond or undertaking to which it is attached."
IN WITNESS WHEREOF, American Contractors Indemnity Company has caused its seal to be affixed hereto and executed by its
President on the 28th day of February, 2003.
CTOts AMERICAN CONTRACTORS INDEMNITY COMPANY
S INCORPORATED
SEPT. 26,1990 <
By;
IFI>ltN~0 .p^
QI Robert F. Thomas, Chief Executive Officer
STATE OF CALIFORNIA §
COUNTY OF LOS ANGELES §
On this 28th day of February, 2003 before me, Norma J. Virgilio, a notary public, personally appeared Robert F. Thomas, Chief Executive
Officer of American Contractors Indemnity Company, to me personally known to be the individual and officer described herein, and
acknowledged that he executed the foregoing instrument and affixed the seal of said-corporation thereto by authority of his office.
NORW J: VIRGILIO
WITNESS my hand and official seal commission#1322310 Z
Notary Public - California
Loa Angeles County
rz
Norma J. Virgilio,Notar My Comm. F)#= Sep 27,2005
I, JAMES H. FERGUSON, Corporate Secretary of American Contractors Indemnity Company, do hereby certify that the Power of
Attorney and the resolution adopted by the Board of Directors of said Company as set forth above, are true and correct transcripts thereof
and that neither the said Power of Attorney nor the resolution have been revoked and they are now in full force and effect.
IN WITNESS HEREOF, I have hereunto set my hand this 1 9 tWay'of Aclu s , 200 4
JAMES AFERGUSON Corporate Secretary
rev. POA04/20/01
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT
State of California
ss.
County of
On car ~9 ~?o~, before me, ~Su 2,4Af M i064 ?Mfi N AJP ~ I'~1 i_ct.13tL4
Date Name and Title of Officer (e.g.,'Jane Doe, Notary Public")
personally appeared I(Yl ~cf /4~ L A F" SK
Name(s) of Signer(s)
OFFICIAL SEAL
SUZANNE PEARMAN
. NOTARY PUBLIC-CALIFORNIA
COMM. NO. 1484858
SAN DIEGO COUNTY
MY 'OMtut. EXP. APRIL 2U 2M
❑ personally known to me
roved to me on the basis of satisfactory evidence
to be the person(a) whose name( is/are-subscribed
to the within instrument and acknowledged to me that
he/shefie~ executed the same in his/herftheif
authorized capacity(iee), and that by his/he their
signature(s) on the instrument the person(s~,-er-#6ie
executed the instrument.
WITNESS my d nd official seal.
Place Notary Seal Above
Signature of Notary Public
OPTIONAL
Though the information below is not required by law, it may prove valuable to persons relying on the document
and could prevent fraudulent removal and reattachment of this form to another document.
Description of Attached Docu e t
Title or Type of Document: G+/✓.1(.rs~ 1~ r
Document Date:/ Dn f Ad- / 210 Number of Pages: a APA
Signer(s) Other Than Named Above:
Capacity(ies) Claimed by Signer(s)
Signer's Name: Signer's Name:
❑ Individual ❑ Individual
❑ Corporate Officer - Title(s): ❑ Corporate Officer - Title(s):
❑ Partner - ❑ Limited ❑ General flil ❑ Partner - ❑ Limited ❑ General
❑ Attorney in Fact Top of thumb here ❑ Attorney in Fact Top of thumb here
❑ Trustee ❑ Trustee
❑ Guardian or Conservator ❑ Guardian or Conservator
❑ Other: ❑ Other:
Signer Is Representing:
2004 National Notary Association 9350 De Soto Ave., P.O. Box 2402 • Chatswor
Signer Is Representing:
I _j
h, CA 91313-2402 Item No. 5907 Reorder: Call Toll-Free 1-800-876-6827
CITY OF ENCINITAS
SAN DIEGUITO WATER DISTRICT
AGENDA REPORT
Meeting Date: January 24, 2007
TO: Board of Directors
VIA: Phil Cotton, District Secretary V FOR YOUR RECORDS
From City Clerk.
Victor Graves, Interim General Manager
FROM: Gary Lee, Engineer I
SDWD Engineering Department
SUBJECT: Consideration of Acceptance of Public Water Improvements and Authorization to
File a "Notice of Completion" for Improvements Constructed by Michael Trask,
for Property Known as Leucadia Hills Subdivision (APNs 254-144-02 & 254-
161-30).
BACKGROUND: On November 14, 2003, the San Dieguito Water District entered into a "Lien
Covenant Regarding Real Property: Improvements Required as Condition on Final Approval of
Subdivision of Real Property" with Michael Trask, owner of property known as Leucadia Hills
Subdivision. The Covenant detailed the requirements for the construction and installation of
certain public water improvements:
ANALYSIS: The potable water improvements were installed in accordance with District
approved plans and specifications, under District inspection. A 25% retention of security will be
held for one year to cover warranty of potable water improvements.
FISCAL. AND STAFF IMPACTS: Future expenses will be incurred for maintenance of the new
water improvements. Funds to cover the cost of said maintenance are collected through the sale of
water.
RECOMMENDATION: Accept public water improvements and authorize the General
Manager or their designee to file a "Notice of Completion" for improvements constructed by
Michael Trask, for property known as Leucadia Hills Subdivision.
)
)
When Recorded Mail To:.
)
District Clerk
)
)
San Dieguito Water District
)
505 South. Vulcan Ave.
)
Encinitas, CA 92024
For the Benefit of the District
NOTICE OF COMPLETION
Assessor's Parcel Nos. 254-144-02 & 254-161-30 Agreement No. A-0067
1. Michael Trask, on the 14th day of November, 2003, entered into an "Improvement Agreement
Regarding. Water Facilities with the San Dieguito Water District. The Agreement detailed the
requirements for the construction and installation of 1 new fire hydrant, new services and appurtenances,
within the subdivision known as Leucadia Hills in the City of Encinitas.
2. Said Covenant, including the plans and specifications for said 'improvements, is on file in the
Office of the Clerk of the Board of Directors.
3. Said improvements were completed by the owners and accepted by the San Dieguito Water
District Board of Directors on the 24th day of January, 2007. ,
4. Subdivision Bond No. 229162 from American Contractors Indemnity Company in the amount of
$27,000.00 maybe released at this time. The District will retain Cash in the amount of $9,000.00, which
shall be released at the end of the one-year warranty period.
5. All requirements of said Agreement have hereby been satisfied except for warranty.
6. Neither acceptance of said improvements by the Board of Directors nor this Notice constitute a
waiver of any defects in the work of the construction or installation of said improvements.
SAN DIEGUITO WATER DISTRICT
Victor Graves
Interim General Manager
VERIFICATION OF BOARD CLERK
I, the undersigned, say:
I am the Board Clerk of the San Dieguito Water District; the Board of Directors of said
District on January 24, 2007, accepted the above described work as completed and
ordered that a Notice of Completion be filed.
I declare under penalty of perjury that the forgoing is true and correct.
Executed on January 24, 2007, at Encinitas; :California.
SAN DIEGUITO WATER DISTRICT
Deborah Cervone
Board Clerk
ACOR_,M
PRODUCER
Driver Alliant Insurance
420 South Broadway
Escondido, CA 92025
License #OC36861.
INSURED.
Downstream Services, Inc
,2855 Progress PI, Ste A
Escondido, Ca 92029
.....................:.:...Y
: ::i::::i::i::::5::;;:;:;i::i::i::i:::................
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DATE (MM/DD/Y )
25/04
8
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
COMPANY
A LANDMARK AMERICAN INS CO.
COMPANY
B GOLDEN EAGLE INSURANCE CORP.
COMPANY
C EMPIRE INDEMNITY INS. CO.-
COMPANY -
D
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 POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR TYPE OF INSURANCE POLICY NUMBER DATE.(MM/DD/YY) DATE (MM/DD/YY) - -
A GENERAL LIABILITY LHA1 24708 11/115/03 11/15/04 . GENERAL AGGREGATE S 2000000
X
COMMERCIAL GENERAL LIABILITY
-
PRODUCTS - COMP/OP AGG
$ 10.00000
CLAIMS MADE I X I OCCUR
PERSONAL & ADV INJURY
$ 1000000
OWNER'S & CONTRACTOR'S PROT
EACH OCCURRENCE
$ 1000000
FIRE DAMAGE (Any one fire)
$ EXCLUDED
MED EXP (Any one person)
$ EXCLUDED
B
AUT
OMOBILE LIABILITY
CBP9565143
-
2/19/04
2/19/05
COMBINED SINGLE LIMIT
S
X
ANY AUTO
1000000.
ALL OWNED AUTOS
BODILY INJURY
$
X
SCHEDULED AUTOS
-
- -
(Per person) - - - -
.
X
HIRED AUTOS
BODILY INJURY
S
NON-OWNED AUTOS
_
-
(Per accident)
- -
-
PROPERTY DAMAGE
$
-
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT
$
ANY AUTO
OTHER THAN AUTO ONLY:
EACH ACCIDENT
$
AGGREGATE
$
C
EXCESS LIABILITY
UM100693
2/19/04
2/19/05
EACH OCCURRENCE
$ 1000000
X
UMBRELLA FORM
AGGREGATE
$ 1000000
OTHER THAN UMBRELLA FORM
$
WORKERS COMPENSATION AND
WC STATU- 0TH
TORY LIMITS ER
EMPLOYERS' LIABILITY
EL EACH ACCIDENT-
$
THE PROPRIETOR/
INCL
EL DISEASE - POLICY LIMIT
$
PARTNERS/EXECUTIVE
OFFICERS ARE:
EXCL
EL DISEASE - EA EMPLOYEE
$
OTHER
*10 DAY NOTICE OF CANCELLATION
FOR NON PAYMENT OF PREMIUM.
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS
RE: LOTS 32, 33 & 35 LEUCADIA HILLS. PIRACUS & PLATE, ENCINITAS, CA.
SAN DIEGUITO WATER DISTRICT, ITS DIRECTORS, OFFICERS, EMPLOYEES OR
AUTHORIZED VOLUNTEERS ARE ADDITIONAL INSURED PER THE ATTACHED
ENDORSEMENT.
SAN DIEGUITO WATER DISTRICT
505 S. VULCAN AVENUE
ENCINITAS, CA 92024-3622
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE. SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPGAL THE COMPAl W, ITS AGENTS OR REPRESENTATIVES.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED
BLANKET PRIMARY
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
SCHEDULE
Name of Person or Organization:
Any person or organization to whom or to which you are obligated by
virtue of a written contract or by the issuance or existence of a
permit, to provide insurance such as is afforded by this policy.
(If no entry appears above, information required to complete this
endorsement will be shown in the Declarations as applicable to this
endorsement.)
A. Section II - WHO IS AN INSURED is amended to included as an insured
the person or organization shown in the SCHEDULE, but only with
respect to liability arising out of your ongoing operations performed
for that insured.
B. With respect to the insurance afforded to these additional
insureds, the following exclusion is added as an item to SECTION I -
COVERAGES, BODILY INJURY AND PROPERTY DAMAGE LIABILITY,
2. Exclusions
This insurance does not apply to "bodily injury" or "property damage
occuring after':
(1) All work, including materials, parts or equipment furnished in
connection with such work, on the project (other than service,
maintenance or repairs) to be performed by or on behalf of the
additional insured(s) at the site of the covered operations has been
completed; or
(2) That portion of "your work" out of which the injury or damage
arises has been put to its intended use by any person or organization
other than another contractor or subcontractor engaged in performing
operations for a principal as a part of the same project.
C. If you are required by a written contract to provide primary
insurance, this policy shall be primary as respects your negligence
and SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, 4. Other
insurance does not apply, but only with respect to coverage provided
by this policy.
This endorsement effective 11/15/03
forms part of Policy Number LHA124708
issued to: DOWNSTREAM SERVICES, INC.
by
Endorsement No.
RSG 15002 0903 Includes copyrighted material of Insurance
Services Office, Inc. 1994 with its permission
CERTHOLDER COPY
STATE P.O. BOX 420807, SAN FRANCISCO, CA 94142-0807
COMPENSATION
I N S U R A N C E
FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 08-25-2004 GROUP:
POLICY NUMBER: 1712375-2004
CERTIFICATE ID: 97
CERTIFICATE EXPIRES: 01-01-2005
01-01-2004/01-01-2005
SAN DIEGUITOIWATER DISTRICT
505 S. VULCAN AVENUE
ENCINITAS CA 92024-3633
JOB: LOTS 32, 33 & 35, LEUCADIA HILLS
PIRACUS & PLATO
ENCINITAS, CA
This is to certify that we have issued a valid Worker's 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 30 days advance written notice to the employer.
We will also give you 30 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
policy 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 to which it may pertain, the insurance afforded by the policy
described herein is subjectto all the terms, exclusions, and conditions, of such policy. -
AUTHORIZED REPRESENTATIVE. PRESIDENT
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE.
ENDORSEMENT #1600 - VICTOR ROBERTS, VP - EXCLUDED.
ENDORSEMENT #1600 - WILMA ROBERTS, P,S,T EXCLUDED.
ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 01-01-2003 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY.
EMPLOYER
DOWNSTREAM SERVICES INC
2855 PROGRESS PL # A
ESCONDIDO CA 92029
SCIF 10262E Accept this certificate only if you see a faint watermark that reads "OFFICIAL STATE FUND DOCUMENT"
[B,SD]
PRINTED: 08-25-2004
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