Laserfiche WebLink
PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY l <br /> JOGI KHANNA M.D.,M.P.H. n' 1 <br /> Hea1111 Officer <br /> P.O. Dux 2009 . (1601 fast Ilazchun Avenue) Stockton, California 95201 <br /> (209) 468.3400 <br /> I' <br /> li <br /> . q <br /> li <br /> ' I <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 all of the questions and <br /> return the original of this letter to Public Health ServiceslllEnvironmental Elealth Division. <br /> I� <br /> Ron Valinoti, Director <br /> Environmental Health Division <br /> BUSINESS NAME Cal -West Concrete Cutting, Ilnc, <br /> BUSINESS ADDRESS 1153 Vanderbilt Ci r.CITY Manteca ZIP 95336 <br /> BUSINESS TELEPHONE (1)209-823-2236 (2) <br /> I� <br /> OWNER #1 waitron Rirrh OWNER #2 <br /> ADDRESS P.O. Box 940-Fremont 9453ADDRESS <br /> PHONE NO.415-656-0253 PHONE- NO. <br /> 320029 76 <br /> CA., CONTRACTOR LICENSE NO. ISSUE DATE�_EXP DATE_ /�3 <br /> LICENSE CLASSIFICATION (A, B, C) -c IF "Ct INDICATE SPECIALTY NOS. <br /> CONCRETE RELATED SERVICES 61/006 <br /> IF "C-61" CLASSIFICATION, INDICATE TYPES LIMITED SPECIALTY/IES <br /> CONCRETE RELATED SERVICES ' <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD <br /> STANDING? YES X NO 1F YOU ARE SUBJECT TO WORKMAN'S <br /> COMPENSATION LAWS OF CALIFORNIA, DO YOU CARRY WORKMAN'S <br /> COMPENSATION INSURANCE? YES X NO_ <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS <br /> DEPARTMENT? YES_ NO IF YES, EXPIRATION DATE <br /> i� <br /> SIGNATURE�� � 4l� <br /> TITLE Branch Manager/Treasure " <br /> DATE_ 7-30'91` , <br /> III <br /> 1.111 00 09 <br /> A Division of San Jwtluin County I Irilth C,or Svrwkrs <br /> d <br />