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r 06/01/2004 07:50 STATE COMPENSATION 4 912094683433 NO.311 0002 CERTHOLDER COPY STATE P.O. BOX 420807,SAN FRANCISCO,CA 94142-0807 COMPENSArrON I N 5 U R A N C E FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 05-28-2004 GROUP: 000713 POLICY NUMBER: 7115-2003 CERTIFICATE ID: 29 CERTIFICATE EXPIRES: 10-01-2004 10-01-2003/10-01-2004 SAN L70AQUIN COUNTY 304 E WEBBER AVE 3RD FL STOCKTON CA 95202 This is to certify that we have issued a valid Workees Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named be ow 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 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 terrns,exclusions,and conditions,of such policies. Az AUTHORIZED REPRESENTATIVE PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #1600 - JOHN F. FAHY, JR. , PRESIDENT SECRETARY- EXCLUDED. ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 04-18-2001 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EUPLOYER FAHY CONSTRUCTION COMPANY, INC. PO BOX 1655 PATTERSON CA 95363 r�cLs.Ne� INTE :08.28.24C- SCIF 10262E Accept thin certificate only iryou see a taint watermark that reads'OFFICIAL STATE FUND DOCUMENT' PAGE 1 OF 1