Laserfiche WebLink
BOARD OF TRUSTEES SAN JOAOUIN LOCAL HEALTH DISTRICT <br />James Culbertson. Pres. <br />Patricia E. Vannuccl, sec's• <br />1601 East Hazelton Avenue, P. O. Box 2009 <br />Tommy Joyce <br />Stockton, California 95201 <br />Earl Plmentel <br />Fern Bupbee <br />209/466-6761 <br />Daniel L. Flores <br />John D. Mast, M.D. <br />William J. Wade <br />Jopl Khanna, M.O., M.P.H., District Health Officer <br />Mary Anna Love <br />RE: CALIFORNIA -LICENSED CONTRACTOR QUESTIONNAIRE <br />SERVING <br />City of Lodl <br />San Joaquin County <br />City of Escalon <br />City of Manteca <br />City of Ripon <br />City of Stockton <br />City of Tracy <br />San Joaquin County <br />San Joaquin County <br />In order to comply with State and Local Laws relative to contractor licensing and <br />Workman's Compensation Insurance requirements, we are asking that you provide this <br />District with the information requested below. Please answer all of the questions <br />and return the original of this letter in the self-addressed envelope provided. <br />BUSINESS NAME I <br />BUSINESS ADDRESS <br />Ron L. Valinoti, Acting Director <br />Enyironmentaj Health Division <br />IP 6 / <br />BUSINESS TELEPHONE NUKBEW(1) <br />OWNER(S) (1) (2) <br />OWNER(S) ADDRESSES (1)�IQc�L2/112) <br />OWNER(S) PHONE NOS (1) / Ci7/p 6y�y2) <br />CA., CONTRACTOR LICENSE NO. / y/ 17;/ 9Y ISSUE DATE 01'Sf XP. DAT 7 31 — 9-9' <br />LICENSE CLASSIFICATION (A,B,C) i2- * "C" INDICATE SPECIALITY NOS. <br />IF "C-61" CLASSIFICATION, INDICATE TYPE/S OF LIMITED SPECIALITY/IES. <br />ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD STANDING? YES /_,--�NO_ <br />IF YOU ARE SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA, DO YOU CARR <br />WORKMAN'S COMPENSATION INSURANCE? YES !/ NO / <br />IF YES, HAVE YOU FILED A /rCERTIFICATE OF INSURANCE WITH THIS DISTRI T? YES NO <br />IF YES, EXPIRATION DATE (-fymt-, - f7 <br />SIGNATU <br />TITLE <br />DATE <br />EH 05 30 7-86 <br />