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PUBLIC <br /> HEALTH <br /> SERVICES a�tN <br /> SAN JOAQUIN COUNTY <br /> r:' c <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officer <br /> P.O. Box 2009 . (1601 Past Hazelton Avenue) Stucktun, California 95201 • c�� �`P . <br /> Igo <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 askin <br /> that You provide this District with the information requested below. 9 <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 /> BUSINESS NAMEAt <br /> BUSINESS ADDRESS <br /> BUSINESS TELEPHONE /1 CITY ,y,�,o J� ZIP <br /> (2) <br /> OWNER #1 t 20 lam„ <br /> ADDRESS f 010, ` � OWNER #2 <br /> �'� �' "� �� S>� SSD ADDRESS <br /> PHONE NO. <br /> PHONE NO. <br /> CA. , CONTRACTOR LICENSE NO. <br /> LICENSE CLASSIFICATION A ISSUE DATE EXP DATE <br /> ( B, C) IF 11C11 INDICATE SPECIALTY NOS. <br /> IF "C-6111 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 WORKMANIS COMPENSATION LAWS OF CALIFORNIA, DO YOU <br /> CARRY WORKMANIS COMPENSATION INSURANCE? YES ��-- <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INS6ANCEOWITH <br /> IF YES, EXPIRATION DATE THIS DISTRICT? Y N <br /> SIGNATURE <br /> TITLE <br /> DATE <br /> A Division of sin Joaquin County Health Crre Services <br />