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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY `s <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officcr <br /> RO. flux 2009 e (1601 Cast Ilazrlcun Avrnue) Scuckcun,California 95201 �'Fo•`-'`'i <br /> (209) 468-3100 <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 F j:>R1L-LI ryU- <br /> BUSINESS ADDRESS 949 O QME5C, e iRCtE� CITY MAX46 69ZO .I IP q51462, <br /> BUSINESS TELEPHONE (1) (2) <br /> OWNER #1 �r�e�� P, Fir A5 OWNER #2 <br /> ADDRESS c aFa- rda Vs ADDRESS <br /> PHONE NO. -I rY6 4'bye PHONE NO. <br /> CA., CONTRACTOR LICENSE NO.5i�ISSUE DATE D 'z13EXP DATEla 3� <br /> LICENSE CLASSIFICATION (A, B, C)c 5;-Z 1F "C" INDICATE SPECIALTY N S._ <br /> IF "C-61" CLASSIFICATION, INDICATE TYPE/S LIMITED SPECIALTY/IES <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD <br /> STANDING? YES_& NO IF YOU ARE SUBJECT TO WORKMAN'S <br /> COMPENSATION LAWS OF CALIFORNIA, DO YOU CARRY WORKMAN'S <br /> COMPENSATION INSURANCE? YES4NO_ <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE wins THIS <br /> DEPARTMENT? YES.L NO_ IF YES, EXPIRATION DATE d <br /> SIGNATURE <br /> 1'I'fLE <br /> DATE '7-2-5-`?ZZ <br /> 1.:11 00 09 <br /> A 1)ivisiun ul$+n Ju+cluin('uunry I lc+hh C+re 5crvitrs <br />