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CITY OF SANTA ANA <br />RFP NO.. 22-096 <br />ON CALL EMERGENCY ASPHALT & PCC <br />CONTRACTOR'S LICENSING AND REGISTRATION 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 (1) ), and that the <br />following is t-me and con-ect. <br />Contractor's Name_ <br />Business Address: ��Z kf— C � <br />Business E-Mail Address: Prvaropvj <br />Telephone: m— Lj <br />State Contractor's License No. and Class <br />License Expiration Date: (v I $ <br />State Dept. of Industrial Relations (DIR) <br />Registration No.: l`6Y�-�-144 <br />State Dept. of Industrial Relations (DIR) <br />Registration Expiratio ate: <br />Signed: <br />Title: <br />Page I of I0 <br />