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PUBL.Il HEALTH SERVICES o.. <br /> SAN JOAQUIN COUNTY <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officer <br /> P.O. Box 2009 e (1601 L•asr Hazelton Avenue) • Stockton, California 95201 4� <br /> (209) 468-3400 <br /> 0 <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 /> BUSINESS NAME c-: INNp�� ` � <br /> BUSINESS ADDRESS �z�' � CITY cq ZIP gS37 (c <br /> BUSINESS TELEPHONE (1) �ZG� �?��� Cj`� (2) <br /> OWNER #1 cacM,,-, L SCjh OWNER #2 <br /> ADDRESS ADDRESS <br /> PHONE NO. g?�� -� � PHONE NO. <br /> CA. , CONTRACTOR LICENSE N -G ISSUE DATE y/GZ EXP DATE <br /> LICENSE CLASSIFICATION (A, DJ C) AIk� 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? (f) 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 WITH THIS DISTRICT?C N <br /> IF YES, EXPIRATION DATE C - C\_q<-� <br /> SIGNATURE <br /> TITLE ; <br /> DATE <br /> A Division of San Joaquin County I Icalth Care Services <br />