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TUBhPfC HEALTH SERVICES p�iN <br /> sANJaAQucN eouNrY <br /> 2•' r .G <br /> JOGI KHANNA M.D.,M.P.H. f <br /> Hcaleh Officer <br /> P.O. Box 2009 a (1601 Bast Hazelton Avenur) . Srucktim, California 95201 • X41IF 0 i <br /> (209) 408-.3400 <br /> 0 <br /> RE: CALIFORNIA LICENSED CONTRACTOR QUES'T'IONNAIRE <br /> In order to comply with State and Local Laws relative to contractor <br /> licensing and Workman ' s Compensation Insurance requirements, we are asking <br /> that you provide this District with the information requested below. <br /> Please answer all of the questions and return the original of this letter <br /> to Public Health Services Environmental Health Division. <br /> Ron Valinoti, Director <br /> Environmental Health Division <br /> BUSINESS *1T,,%yE <br /> BUSINESS ADDRESS (nth 1(y;:�& � CITY � c ZIP c{ <br /> BUSINESS TELEPHONE (1) oZ _ p' (2)I <br /> OWNER #1 OWNER #2 <br /> ADDRESS ADDRESS <br /> PHONE NO. PHONE NO. <br /> CA. , CONTRACTOR LICENSE NO. 51 ISSUE DATES EXP DATE <br /> LICENSE CLASSIFICATION (A, B, C) �-2- IF "C" INDICATE SPECIALTY NOS. <br /> IF "C-51" CLASSIFICATION, INDICATE TYPE/S OF LIMITED SPECIALTY/SES <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD STANDING? N <br /> IF YOU ARE SUBJECT TO WORKMAN' S COMPENSATION LAWS OF CALIFORNIA, DO YOU <br /> CARRY WORKMAN' S COMPENSATION INSURANCE? YES 4 NO <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT? YO N <br /> IF YES, EXPIRATION DATE py- <br /> SIGNATURE <br /> TITLE <br /> DATE <br /> A Nyis6n of San jnagLjin Guonty I'eakh Circ Soviet¢ <br />