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04-21-93 1139A F1 <br /> PUBLIC HEALTH SERVICES <br /> SAN)OAQUINCOUNTY ` <br /> JOGI KHANNA MD,W.H. Z <br /> Health 0(faee '; . <br /> P.O.Box 2009 . (1601 Ease Hueleon Avenue) • Srucktun,CIifurnis 95201 a <br /> (209)46R•3400 <br /> lsee. CoWf keAty, L'*M k� <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 11 OWNER 12 <br /> ADDRESS ADDRESS <br /> PHONE NO. PHONE NO. <br /> CA. , CONTRACTOR LICENSE NO. ISSUE DATE EXP DATE <br /> LICENSE CLASSIFICATION (A, B, C) IF "C11 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 Divyim of%n j,.gv;n C--wy Heahh C,q-.A rrits <br />