Laserfiche WebLink
A <br /> • a <br /> PU*15LIC <br /> HEALTH <br /> 1 <br /> .Rl.CQt . <br /> 5 NJ4AQUIN COUNTY �"--,�. fio <br /> JOGI KNANNA MR,MAU � 4 <br /> Health OfficerPOAOX ?� K <br /> 009 • iG01 last Hazelton Avenue) w Ste'ek't,n, iliftrrnir�J53f�1 'c,� <br /> (2019)468.3400 <br /> FNVP0NMENTAL Hg <br /> RE.: CALIFC7RNZA IC:EN.SED CONTRACTOR Ei�n�tIUSE"dE <br /> QUESTICINNAIRE <br /> .In order to comply with State and. LocaI Laws relative to Contractor <br /> licensing and Workman'$ Compensation Insurance requirements, we are asking.. <br /> that you provide this District with the information requested below. <br /> Please answer all. of the q, estions and return the original of this letter <br /> to Psbl C HealthS.ervi:ces Environmental. Health Division. <br /> Ron Valinoti., Director <br /> Environmental Health Division <br /> BUSINESS NAM r ' <br /> BUSINESS ADDRESS <br /> CITY _�5- Z IP <br /> BUSINESS TELEPHONE {i} �77t � Z l ' ri fit <br /> OWNER 11 OWNER 12 <br /> ADDRESS 1 Q- —C kSSu le . �l C ADDRESS <br /> PHONE; Nn. (-�A qq:_?.- � < PHONE Nd.. <br /> CONTRACTOR UCEXSE NO. � q � ISSUE DATE { <br /> LICENSE CLASSIFICATION EXP DA'Z'E; <br /> { :c 8, C) _ G. IF` "Coy INDI ATE SPECT LT.YC 8(35., <br /> IF "C-fil" CLASSIFICATION, INDICATE TYPE/S OF LIMITED SPECIAL ES <br /> ARE THE LICENSES LISTED ABOVE :CURRENTLY ACTIVE AND IN GOOD STANDING?:.:Y t :N <br /> IF YOU ARE SU$J$CT TO WOJ�K Nr::S. COMPENSATION' LAWS OF C"IFORNIA:, DO YOU <br /> CARRY WqRK%4►N'.D COMPENSA"O$ ;INSURANCE? 'YES <br /> No <br /> IF` YES.., 809 YOU FILED1A CERTIFICATE OF INSURANCE *TR :THIS A.ISTRICTs:: Y~► N <br /> IF YES, tXPIRATION :DATE <br /> SIGNATURE <br /> TITLE <br /> DATE ( <br /> A Division of flan j02gt+in CmintY WrAlth frrr Cctvitrs <br />