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LEN? P`!:A9u6.6eo=cience Inc. ="" 4- q-91 3:01Pr1 <br /> PUBLI HEALTH SERVICES <br /> SANIUAQUIN CAUN1Y <br /> JWI KHANNA M.D.,M.P.II, <br /> tete <br /> ft h drlkee � <br /> A0. flux 2009 + (, w Stuclttun,Calirurniv 95201 <br /> (2o,)) 468.mw 3gA0 ' <br /> C11 1g9.I <br /> AQ"A sengo-A 6N <br /> r;f o 1 Wt'a"• T%41 Nb Uzt�-L� 1L <br /> 144tsr t bl CA 1'660 i <br /> RE: CALIFORNIA LICENSED CONTRACTOR QUESTIONNAIRE <br /> In order to comply with Sirite and Local Laws relative to cantructor licensin' and <br /> Workman's Competuation Insurance requirentents, we are asking that you provide this <br /> Department with the informatlu�n requested below, Please answer all of the questions and <br /> IVIUM the nrigtnui of this letter to Publlc Health Sorvices Environmental Hertith Division. <br /> Ron Vallnoti, Director <br /> Environmental Health DlvIsion <br /> BUSINESS NAM ,EENCEs INC. <br /> BUSINESS ADDRFSS 1701 WESTWIND DRCITY $AKERSFIELTJZIp 93301 k <br /> BUSINESS TELEP110NE (1)805--328-0962 (2) r <br /> 6 <br /> OWNER #1 PHILIP GOALWIN OWNER #2 <br /> ADDRESS 2208 WILD OAK CT. ADDRESS,,,��, ,,., ..,....�.� <br /> P110NE NO. 805-664-0876 PHONE NO, <br /> 89 I <br /> CA., CONTRAC'T`OR LICENSE No, 477� ISSUE DATE 6 30 E3rrP DATE-64-30/92 <br /> LICENSE CLASSIFICA'I"ION (A, B, C)-----.IF ':.C" INDICATE SPI3C1ALTY NOS, <br /> IF "C-61" CLASSIFICATION, INDICATE TYPElS LIMITED SPECIALTY/113S. <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD <br /> STANDING? YES,x NO_,,,, IF YOU ARE SUBJECT TO WORKMAN'S <br /> COMPENSATION LAWS OF CALIFORNIA, DC YOU CARRY WORKMAN'S <br /> COMPENSATION INSURANCE? YESx NQ— <br /> IF YES, HAVE YOU FILED A CERTIFICA'T'E OF INSURANCE WITH THIS <br /> DEPARTMENT? YES_Z NO,,,_, I1~ YES, EXPIRATIONDA 'E <br /> THE UNDERSIGNED HAS THE AUTHORITY •T S ON LL G PERMITS , <br /> SIGNATURE <br /> TITLE <br /> I)ATl3 04109/91 <br /> XII dv 00 A Dlrl{iun tid$rn'ewHuin t'uwu� f i4'�IiIY t.►�!kt.icetJ <br /> � • d �� :e� t 6�en!tio �an�� <br />