Laserfiche WebLink
PUBLIC <br /> HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officer <br /> P.O. Box 2009 . (1601 Past Hazelton Avenue) . Stockton,California 95201 cit <br /> �FpH <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. 5 <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 NAME I <br /> BUSINESS ADDRESS <br /> BUSINESS TELEPHONE CITY � ��;lj ZIP <br /> -�8S (2) <br /> OWNER #1 4DD.VP <br /> L�Y�i,c, c� OWNER #2 <br /> ADDRESS —iZ�� ADDRESS <br /> PHONE No. <br /> PHONE NO. <br /> CA. , CONTRACTOR LICENSE NO. <br /> 79 <br /> LICENSE CLASSIFICATION (A, B 5C SS, ISSUE DATE EXP DATE <br /> IF "CIF 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 WITN THIS DISTRICT Y <br /> IF YES, EXPIRATION DATE <br /> SIGNATURE <br /> TITLE <br /> DATE <br /> A Division of San Joaquin Gatnty Health Crre Services <br />