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PUBLIC HEALTH SERVICES PplJ�ry <br /> o <br /> SAN JOAQUIN COUN'T'Y <br /> JOG]KHANNA M D,M P H " <br /> Health Officer <br /> P O Box 2009 . (1601 East Hazelton Avenue) . SLOCkton, California 95201 C4��F 0*a <br /> (209) 468-3400 <br /> RE: CALIFORNIA LICENSED CONTRACTOR QUESTIONNAIRE <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 /> BUSYNESS NAME <br /> BUSINESS ADDRESS CITY ZIP <br /> BUSINESS TELEPHONE (1) (2) <br /> OWNER #1 OWNER #2 <br /> ADDRESS ADDRESS <br /> PHONE NO. PHONE NO. <br /> CA. , CONTRACTOR LICENSE NO. ISSUE DATE EXP DATE <br /> LICENSE CLASSIFICATION (A, B, C) IF "C" INDICATE SPECIALTY NOS. <br /> IF "C-61" CLASSIFICATION, INDICATE TYPE/S OF LIMITED SPECIALTY/IES <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD STANDING? Y N <br /> IF YOU ARE SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA, DO YOU <br /> CARRY WORKMAN' S COMPENSATION INSURANCE? YES NO <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT? Y N <br /> IF YES, EXPIRATION DATE <br /> SIGNATURE <br /> TITLE ,._.._.._.... � <br /> DATE <br /> A Division of San Joaquin County He i1th Care Services <br />