Laserfiche WebLink
CITY OF SANTA ANA <br />RFP NO.: 22-096 <br />ON CALL EMERGENCY ASPHALT & PCC <br />CONTRACTOR'S LICE SING AND REGISTRATIOI�I STATEMENT <br />The undersigned contractor, or corporate officer, declares under penalty of perjury that he/she and all his/her <br />subcontractors are registered with the State of California Department of Industrial Relations (DIR), and that the <br />following is true and correct. <br />Contractor's Name: <br />Business Address: <br />Business E-Mail Address: <br />Telephone: _ _f ILI1 �D6lp-- j L4 <br />State Contractor's License No, and Class: a( D <br />License Expiration Date: lQ I'S6� 7 <br />State Dept. of Industrial Rotations (DCR) <br />Registration No.: <br />State Dept, of Industrial Relations (DIR) <br />RegistrationExpiratiqA4-)ate: / <br />Signed: <br />Title: <br />Page I of 10 <br />