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HEALTH SERVICES o��u'PUBLICt .� .� <br /> SAN JOAQUIN COUNTY <br /> JOGI KHANNA M.Q.,hi-P,11. '• <br /> Ieallh Office( .. <br /> P.O. Ilux 2009 + (1601 Pau I laxrlton Munur) +'Stucl:wn,Culifornir 95201 <br /> (209) 468-5400 1PITIVE, <br /> ,SAN 15 1992 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> RE: CALIFORNIA LICENSED CONTRACTOR QUESTIONNAIRE <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 /> Department with the information requested below. Please answer ail of the questions and <br /> return the original of this letter to Public 1leallh Services Environmental Health Division. <br /> Ron Valinoti, Director <br /> Environmental Health Division <br /> BUSINESS NAME,,, <br /> BUSINESS ADDRESS CITYs_o6x=eEoQ,> ZIT' 3-r <br /> BUSINESS TELEPHONE (1) 11.8 j--!;-7o (2) <br /> OWNER #1 Fcgis tiAoAF, _.... OWNER #1 <br /> ADDRESS_1s3�tt RNs. Tout +2D ADDRESS <br /> PHONE NO. '6( 8 1 T7o PHONE NO. <br /> CA., CONTRACTOR LICENSE NO. gs-)6-7 c ISSUE DATE 4181 EXP DATE—z 9 z <br /> LICENSE CLASSIFICATIONA, B, C) IF "C' INDICATE SPECIALTY NOS._ <br /> "►s. R <br /> IF "C-61" CLASSIFICATION, INDICATE 'f YPE/S LIMITED SPECIAL'VICS <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD <br /> STANDING? YES ,✓ NO IF YOU ARE SU13JECT TO WORKMAN'S <br /> COMPENSATION LAWS OF CALIFORNIA, DO YOU CARRY WORKMAN'S <br /> COMPENSATION INSURANCE? YES-,,::fNO_ <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITI•i THIS <br /> DEPARTMENT? YES—L---NO— ll~ YES, EXPIRATION DATE— <br /> SIGNATURE -i aA �L4 <br /> TITLE 062,,,% -- <br /> DATE„__4_ <br /> l31 00 00 <br /> A r7iri9iun u1San fuarluin County l IcAUh('ire k•iri.ci 1� <br />