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PUBLC HEALTH SEWICES <br /> SAN JOAQUIN COUNTY <br /> JOGI KHANNA RD,M.P.H. <br /> Health Officer c ''• <br /> P.O. Box 2009 . (1601 East Hazelton Avenue) • Sturktun, 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 <br /> BUSINESS ADDRESS CITY ZIP <br /> BUSINESS TELEPHONE (1) (2) <br /> OWNER i#1 OWNER t2 <br /> ADDRESS ADDRESS <br /> PHONE NO. PHONE NO. <br /> CA. , CONTRACTOR LICENSE NO. ISSUE DATE EXP DATE <br /> LICENSE CLASSIFICATION (A, B, C) IF "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? 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 WITH THIS DISTRICT? Y N <br /> IF YES, EXPIRATION DATE <br /> SIGNATURE <br /> TITLE <br /> DATE <br /> A Division W San Jna9uin Gmnty Health Gus•Ss•rvicm <br />