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PUBLIC. HEALTH SEXICES <br /> SAN JOAQUIN COUNTY r z <br /> N: < <br /> JCXiI KNANNA M.D.,M.P.il. <br /> 11calih Officcr <br /> R U. flux 2009 . (1601 Fast i lazclrun Avcnuc) . Stockwn, California 05201 <br /> (209) 46H-3.100 <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 I Iealth Services Environmental health Division. <br /> Ron Valinoti, Director <br /> Environmental Flealth Division <br /> BUSINESS NAME is C-Jr\v)'"m,'h-eAA'a n5UItat,, S <br /> � <br /> BUSINESS ADDRESS S r-enY <br /> IT ( vajZIP C I SVI4e aq�), <br /> BUSINESS TELEPHONE (1)_Z4( 3R l b (2) <br /> T-4 (3 <br /> OWNER #1Clw �,�ctwi� V�1t OWNER #2 <br /> ADDRESS 3 1�r�/.aa aCkADDI.ESS <br /> PHONE NO. c14S7,3Pi-TONE NO. <br /> CA., CONTRACTOR LICENSE NO. � 40 ISSUE DATE I EXP DATE 3 t q,> <br /> LICENSE CLASSIFICATION (A, B, C) A, "C' INDICATE SPECIALTY NOS._ <br /> �.5 r7 -* (0Z4Y6 I 4-40 AW <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 t/ NO 1F YOU ARE SUBJECT TO WORKMAN'S <br /> COMPENSATION LAWS OF CALIFORNIA, DO YOU CARRY WORKMAN'S <br /> COMPENSATION INSURANCE? YES_✓NO <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WI"I'I-I THIS <br /> DEPARTMENT? YES✓ NO IF YES, EXPIRATION DATE <br /> J <br /> SIGNATURE' , AY) <br /> TITLE j, <br /> DATF8' 1� -�1 <br /> EH 00 Og <br /> A Division of S.n jujquin Ctmmy 1(cj If II Cite Scry it c: <br />