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.eUbLft, r1rAL1fR ,-3tRVICES ,?_`i�;"'; A <br /> SAJCJAYUN Wu NTY r. y <br /> JOGi KH.ANNA M.D.,MT H <br /> He,l°h U(ficer <br /> P.0 Box 2009 + (1601 Lau Hawlron Avenur) . Stockton. Cilifornia ')S2U; "?!% <br /> (204) 468.34OU <br /> CALIFORNIA LICENSED CONTRACTOR QUESTIONNAIRE <br /> order to Comply with State and Local Laws relative to contract_ <br /> sensing and Workman0s Compensation Insurance requirements , we are asking , <br /> it you provide this District with the information requested Lel: <br /> ,age answer all of the questions and return the original of tf Atter <br /> public Health Services Environmental Health Division . <br /> Ron Valinoti, Director <br /> Environmental Haalth <br /> BUSINESS NAME �AJC-S 0.Z-vv%c0.K �C , `l, ✓� " C <br /> BUSINESS ADDRESS , r fz e1g a!d CITY ZIP <br /> "'iINESS TELEPHONE (1) 6 5 - 7 ]b (2) 9�E - 635 <br /> OWNER 01 �j 0 w. ZO 0n e V OWNER 02 Bco e /uN": a-._ ' �C'-( <br /> ADDRESS 27 7D L'uv H C D. ADDRESS /ep/,d G'`ku <br /> PHONE No. �rC y -- Co PHONE NO. 7/�l9 <br /> CA. , CONTRACTOR LICENSE NO. � 77 7 ISSUE DATE -/- 70 EXP DATE <br /> CENSE CLASSIFICATION (A, B, C) _ IF 11C" INDZCATE SPECIALTY Nc,". � <br /> IF "C-6111 CLASSIFICATION, INDICATE TYPE/S �F LIMTyPECIALTX/SES <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD STANCINGI N <br /> IF YOU ARE SUBJECT TO WORKMAN ' S COMPENSATION LAWS OF CALIFORNIA, 00 YOU <br /> CARRY WORKMAN °S COMPENSATION .LNSURANCE? YESNO w <br /> IF YES, . VF YOU FILED A CERTTFT. CATE OF INSURANCE WITH THIS DISTRICT. N <br /> Ir , "•,ATION DATE <br /> VIV <br /> SIGNATUR <br /> !'ITLE . <br /> nh^nk+ 3/�!'� <br /> `1 <br /> s <br />