Laserfiche WebLink
PUBLIC HEALTH SERVICES ,qa'tl qk <br /> SAN JOAQUIN COUNTY <br /> JOG[ KHANNA M.D.,M.P.H. <br /> Hulth Officcr <br /> P.O. Box 2009 (1601 East liazelion Avcnuc) Stockton, California 95201 <br /> (209) 468.3400 <br /> APR <br /> It, L <br /> I V; <br /> RF.: 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 411 of the qu;s.jjor4 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 <br /> BUSINESS ADDRESSCITY* ZIP E! Y <br /> _ QCHAR <br /> BUSINESS TELEPHONE S-� Iq 711-3�C11(92j <br /> OWNER OWNER #2 <br /> ADDRESS 561 AcKj�pe St ADDRESS <br /> PHONE NO. Q47 PHONE NO. <br /> CA., CONTRACTOR LICENSE NO. 553 k.9 C, ISSUE DATE vzjgq�EXP DATE <br /> LICENSECLASSIFICATION (A, B, C) C IF "C" INDICATE SPECIALTY NOS.— <br /> !E? <br /> IF "C-61" CLASSIFICATION, INDICATE TYPE/S LIMITED SPECIALTY/IES— <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD <br /> STANDING? Yr--S- NO— IF YOU ARE SUBJECT TO WORKMAN'S <br /> COMPENSATION LAWS OF CALIFORNIA, DO YOU CARRY WORKMAN'S <br /> COMPENSATION INSURANCE? YES�70_ <br /> IF YES, HAVE YOU ,FILED A CERTIFICATE OF INSURANCE WITH THIS <br /> DEPARTMENT? YESNO— IF YES, EXPIRATION DATE t?–/g <br /> SIGNATUR <br /> TITLE— <br /> DATr,, 9% �O <br /> Ell 00 09 A Di,6iun f$,n Joaquin Co,Imy I[c,J.1.G¢5"v j,a,, <br />