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• 0 <br />PUBLIC HEALTH SERVICES <br />SAN JOAQUIN COUNTY <br />JOGI KHANNA bl.D., M.P.H. <br />Hcalih Officer <br />P.O. Bux 2009 . (1601 Easc Hazchun Avenuc) . Srockron, Califurnia 95201 <br />(209)46B-3400 <br />RE: CALIFORNIA LICENSED CONTRACTOR QUESTIONNAIRE <br />In order to comply with State and Local Laws relative to contractor licensing and <br />Workman's Compensation Insurance requirements, we are asking that you provide this <br />Department with the information requested below. Please answer all of the questions and <br />return the original of this letter to Public Health Services Environmental Health Division. <br />Ron Valinoti, Director <br />Environmental Health Division <br />BUSINESS NAME T4 (r& 67-re.N fir.) V I YboNst kl+41 <br />BUSINESS ADDRESSZ333 6rn,44 AvC. CIT (or z <br />BUSINESS TELEPHONE (1Y41s) 4F</- 75160 (2 <br />OWNER #13 n o0ri N , OWNER #2 & � U oto <br />ADDRES Lv-? Allsbai,4• ADDRESSS2r F,,= >c�_ Pd. , '-;aufhkgb CA - <br />PHONE NO(4i5) 5 — 72,7 PHONE NO l4( 51 34--1 ZZ?� <br />CA., CONTRACTOR LICENSE N05if`1640 ISSUE DATES ,`EXP DATE <br />LICENSE CLASSIFICATION (A, B, C) A IF "C' INDICA E SPECIALTY NOS._ <br />1F "C-61" CLASSIFICATION, INDICATE TYPE/S LIMITED SPECIALTY/lES <br />ARE THE LICENSES�ISTED ABOVE CURRENTLY ACTIVE -AND IN GOOD <br />STANDING? YESV NO_ IF YOU ARE SUBJECT TO WORKMAN'S <br />COMPENSATION LAWS OF CALIFOI;NIA, DO YOU CARRY WORKMAN'S <br />COMPENSATION INSURANCE? YES NO_ <br />IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS <br />DEPARTMENT? YES / NO_ IF YES, EXPIRAAATION DATE <br />PII 00 09 <br />S <br />DA <br />A Division of Sanloaquin Gmniy HrAh Carr Srrvitrs 0 <br />