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I <br /> .- - !PP• . <br /> HEALTH SERVICES <br /> PUBLIC <br /> II SAN JOAQUIN COUNTY e JOGI KHANNA M.D.,M.P.I1. <br /> Health Officer . <br /> 1?0. Box ?009 . (1601 Flaw Ilaxrl�un Avrnur) ScacAtun,C:ilifurnia 95201 <br /> icrFa-=i <br /> (209) 469-3400 r OF *. <br /> f <br /> !l APR ' 1 1;911 <br /> "L HEALTP, <br /> PER KAIIT/SERVICES <br /> IZE: CALIFORNIA LICENSED CONTRACTOR QUESTIONNAIRE <br /> la <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 tol Public Health Services Environmental 1-Iealth Division. <br /> :I <br /> gRon Valinoti, Director <br /> Environmental Health Division <br /> BUSINESS NAME <br /> BUSINESS ADDRESS269 Mount Hermon RDCITYScott s V211F-jP 95066 <br /> BUSINESS TELEPHONE (1f-08:-438-7511 (2) <br /> OWNER #1Tim Glass '.� OWNER #2 <br /> ADDRESS 1507 Wharf Rd . CapitolADDRESS <br /> PHONE NO. PHONE NO. <br /> CA., CONTRACTOR LICENSE;'NO.575662 ISSUE DATE_8L21 /_FRCP DATE <br /> LICENSE CLASSIFICATION (A; B, C) A IF "C" INDICATE SPECIALTY NOS.— <br /> IF "C-61" CLASSIFICATION, INDICATE TYPE/S LIMITED SPECIALTY/IES <br /> ARE THE LICENSES LISTED ABOVE CURREN'T'LY ACTIVE AND IN GOOD <br /> STANDING? YES, NO— j— IF YOU ARE SUBJECT TO WORKMAN'S <br /> COMPENSATION LAWS OF i'CALIFORNIA, DO YOU CARRY WORKMAN'S <br /> COMPENSATION INSURANCE? YESX NO— ` <br /> IF YES, HAVE YOU FILEDII A CERTIFICATE OF INSURANCE WITH THIS <br /> DEPARTMENT? YES XXNO-11 IF YES, EXPIRATION DATE <br /> i1SIGNATURE w <br /> 11TITLE Pro ject--Engineer <br /> rDATE2,g M�r.lI Q Q j - — -- <br /> ii <br /> 1.111 00 09 11 <br /> A givis+cm of S+nJuaiquin Cuumy'}Icalli['srr Srrvicx <br />