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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 (DIR), and that the <br />following is true and correct. <br />Contractor's Name: Vido Samarzich, inc. <br />Business Address: 6829 Billings Place, Rancho Cucamonga, CA 91701 <br />Business E-Ma's/ Address: vidosam@yahoo.com <br />Telephone: (909) 987-6377 <br />State Contractor's License No. and Class: 433210 A <br />License Expiration Date: 12/31/2024 <br />State Dept. of Industrial Relations (DiR) <br />Registration No.: 1000013213 <br />State Dept, of Industrial Relations (DIR) <br />Registration Expiration Date: <br />s <br />Signed: <br />Title: Vice President <br />06/30/2023 <br />Page ! of 10 <br />