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PUBLIC HEALTH o�... .....� <br /> SAN JOAQUIN COUNTY a \ < <br /> JOGI KHANNA M.D.,M.P.H. �X <br /> Health Officer <br /> P.O.Box 2009 . (1601 East Hazelton Avenue) . Stockton,California 95201 FON <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 Grefir+ I' 11 IN6 TSS- o <br /> BUSINESS ADDRESS Ar, ITy ( ZIP q 4 5 Z(7 <br /> BUSINESS TELEPHONE (1) (4! S - &5i -yL 2 (2) <br /> OWNER 11 OWNER , 2 <br /> ADDRESS ADDRESS <br /> PHONE NO. PHONE NO, <br /> CA. , CONTRACTOR LICENSE NO. ISSUE DATE �-- EXP DATE 9 <br /> LICENSE CLASSIFICATION (A, B, C) �_ IF "C" INDICATE SPECIALTY NOS. <br /> IF 11C-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 X NO <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT?OY N <br /> IF YES, EXPIRATION DATE o ct <br /> SIGNATURE <br /> TITLE t\k_ <br /> DATE At�n.�SZ �.,5 k(-�IRc> <br /> A Division of Sin Joaquin Gainty Health Care Services <br />