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CITY OF SANTA ANA <br />PROPOSAL <br />PROJECT NO,: 17-7522 AND 15-6836 <br />RESIDENTIAL STREET REPAIR PROGRAM <br />CONTRACTOR'S LICENSING AND REGISTRATION STATEMENT <br />The undersigned contractor, or corporate officer, declares under penalty of perjury that he/she <br />and all his/her subcontractors are registered with the State of California Department of Industrial <br />Relations (DIR), and that the following is true and correct. <br />Contractor's Name: <br />Business Address: <br />Business E -Mail Address: <br />v1 n -i -n e 2n n Genn hti� <br />Telephone: qu C1 — 3?J b — � � 2,Q7 v <br />State Contractor's License No. and Class: <br />License Expiration Date: <br />N <br />State Dept. of Industrial Relations (DIR) <br />Registration No.: � 0 C) 0 () o a LI <br />State Dept. of Industrial Relations (DIR) <br />Registration Expiration Date: <br />Signed:/` - <br />Title: <br />P -4P 16 <br />23A-17 <br />