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PUBL11" HEALTH SEP"' 710ES-*ftw.j <br /> SAN JOAQUIN COUNTY <br /> JOGI KHANNA M.D.,M.P.H. <br /> I(ealtlt Off icer <br /> P.U. flux 2009 (1601 fast I laschutt Avcnuc) Stucktutt, California 95201 %Fo•r^moi <br /> (209) 468.3400 <br /> RE: CALIFORNIA LICENSED CONTRACTOR QUESTIONNAIRE <br /> In order to comply with State and Local Laws relative to contractor licensing and <br /> Workman's Compensafion Insurance requirements, we are risking that you provide this <br /> Department with the information requested below. Please answer all of the questions Gild <br /> return the original of dris letter to Public I iealth Services Environmental FIculth Division. <br /> Ron Valinoti, Director <br /> Environmental Health Division <br /> BUSINESS NAME_ <br /> BUSINESS ADDRESS CI'rYk/ <br /> BUSINESS TELEPHONE (1)t,T�G� 373 —d/sem' (2) <br /> OWNER #1' SYGyiE s em►/ ,f/ OWNER #2 <br /> ADDRESS oo. gox w saw ADDRESS <br /> PHONE NO. PHONE NO. <br /> CA., CONTRACTOR LICENSE NO.s3-sr—zI98 ISSUE DATE iz 8 EXP DATE <br /> LICENSE CLASSIFICATION (A, B, C) e-�7 IF ''C' INDICATE SPECIALTY NOS._ <br /> S> <br /> IF "C-61" CLASSIFICATION, INDICATE 'TYPE/S LIMITED SPECIALTY/l ES <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD <br /> STANDING? YES v1 NO— IF YOU ARE SUDJECT TO WORKMAN'S <br /> COMPENSATION LAWS Of: CALIFORNIA, DO YOU CARRY WORKMAN'S <br /> COMPENSATION INSURANCE? YES INO— <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WI'rui THIS <br /> DEPARTMENT? YES✓NO_ IF YES, EXPIRATION DATE_ 2 y3 <br /> r <br /> SIGNATURE j <br /> AitL T Ab, <br /> �rl•rLE � <br /> DATE- <br /> 1.:11 00 09 <br /> A 1)iriti"n u(S.n Juryuin e'n"nry I Ic,lih r' re Scrri.cs <br />