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PUBLIC HEALTH SERVICES <br />SAN JOAQUIN COUNTY <br />JOGI KHANNA M.D., M.P.H. <br />Health Officer <br />P.O. Box 2009 • (1601 East Hazel= Avenue) • Stockton, California 95201 <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 asking <br />that you provide this District with the information requested below. <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 WrA -v\ O S% 'L-c>r\ -(NIVAA.k-ek l Q_..(-Ai ce.,s <br />1 BUSINESS ADDRESS ut( Ei. )00.4, CITY X ‘ ZIP 9S7S-7,(4, <br />BUSINESS TELEPHONE (1) a04-`i5737?)-Cyls-r-6 (2) <br />OWNER #1 .i.V6Vmn, .t__AvC3.4,\ OWNER 02 /neAs....t._ LIA,C)IN ADDRESS iciLi 14'.0 krfe._,,... Lanl -Ccso...e...V....ci< ADDRESS 01-..1 14; ti kt, e__,....%3 <br />PHONE NO. 0-0'i-5.3a.-f..-3/6;4 ' PHONE NO. <br />CA., CONTRACTOR LICENSE NO.v:,-/S-01 ISSUE DATE (1/(72._ EXP DATE slih(f <br />LICENSE CLASSIFICATION (A, B, C) "C" 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? N <br />IF YOU ARE SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA, DO YOU <br />CARRY WORKMAN'S COMPENSATION INSURANCE? YES \IC NO <br />IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT?&77)N <br />IF YES, EXPIRATION DATE <br />SIGNATURE [U(.41_ <br />TITLE <br />DATE <br />A Division of S.n Joaquin County licalth Cac Servit.es 0