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PUBLIC HEALTH SERVICESN o.�UI. . .� <br /> SAN JOAQUIN COUNTY <br /> JOGI KHANNA M.D.,M.P.H. u <br /> Health Officer ' c j— <br /> P.O. Box 2009 . (1601 East Hazelton Avenue) Stockton, California 95201 9-$roll <br /> (209) 468.3400 <br /> RE: CALIFORNIA LICENSED CONTRACTOR QUESTIONNAIRE <br /> In order to comply with State and Local Laws relative to contractor <br /> licensing and Workman ' s Compensation Insurance requirements, we are asking <br /> that you provide this District with the information requested below. <br /> Please answer all of the questions and return the original of this letter <br /> to Public Health Services Environmental Health Division. <br /> Ron Valinoti, Director <br /> Environmental Health Division <br /> BUS=NESS NAME l c-:��,�� t <br /> BUSINESS ADDRESS �,, J ip",� CITY ZIP 9S37 <br /> BUSINESS TELEPHONE (1) (2) <br /> OWNER #1 OWNER #2 <br /> ADDRESS f I-(v�l( V; �� �; T�.C �C�ADDRESS <br /> PHONE NO. PHONE NO. <br /> CA. , CONTRACTOR LICENSE N CI ISSUE DATE Wg-7 _ EXP DATE 2Z21h 5z <br /> LICENSE CLASSIFICATION (A, BJ C) A Hsuz- 3 IF "C" INDICATE SPECIALTY NOS. <br /> IF "C-61" CLASSIFICATION, INDICATE TYPE/S OF LIMITED SPECIALTY/IES <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD STANDING? C1 N <br /> IF YOU ARE SUBJECT TO WORKMAN ' S COMPENSATION LAWS OF CALIFORNIA, DO YOU <br /> CARRY WORKMAN' S COMPENSATION INSURANCE? YES � NO <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITII THIS DISTRICT? YJ N <br /> IF YES, EXPIRATION DATE JQ - CN-9<� <br /> SIGNATURE vwv <br /> TITLE ; <br /> DATE <br /> A Div isi"n of Sin Joaquin Gnimy I Ica hh Care Services <br />