Registration Services:: Page 1 of 2 6/15/2022 3:23:23 PM
APPLICATION FOR
PUBLIC WORKS CONTRACTOR REGISTRATION
Registration Information
Type: Public Works
Period: 07/01/2022 06/30/2025
Contractor Information
Contractor Name: PUBLIC RESTROOM COMPANY
Trade Name: PUBLIC RESTROOM COMPANY
License Type Number: 1000005303
Contractor Physical Address
Physical Business Country: United States of America Physical Business City/ Province:
MINDEN
Physical Business Address: 2587 BUSINESS PARKWAY Physical Business State: NV Physical Business Postal
Code:
89423
Contractor Mailing Address
Mailing Country: United States of America Mailing City /Province: MINDEN Mailing Address: 2587 BUSINESS PARKWAY Mailing State: NV Mailing Postal Code: 89423
Contact Info
Daytime Phone: Daytime Phone Ext.:
Mobile Phone: Business Email: licensing@publicrestroomcompany .com
Applicant’s Email: [email protected]
Registration Services:: Page 2 of 2
Workers’ Compensation
Professional Employer Organization (PEO)
Do you lease employees through Professional Employer Organization? No
Workers’ Compensation Overview
Carrier: WCF National Inception Date: 06/30/2019
Policyholder Name: PUBLIC RESTROOM COMPANY Expiration Date: June 30, 2023 Policy Number: 4008614
Certification
Yes I certify that I do not have any delinquent liability to an employee or the state for any assessment of back wages or related damages, interest, fines, or penalties pursuant to any final judgment, order, or determination by a court or any federal, state, or local administrative agency, including a confirmed arbitration award I certify that the contractor is not currently debarred under Section 1777.1 or under any other federal or state law providing for the debarment of contractors from public works.
Yes I certify that one of the following is true: (1) I am licensed by the Contractors State License Board (CSLB) in accordance with Chapter 9 (commencing with Section 7000) of the Business and Professions Code; or (2) my business or trade is not subject to licensing by the CSLB.
I understand refunds are not authorized
I, Jennifer Garlington, the undersigned, am , PUBLIC RESTROOM COMPANY with the authority to act for and on behalf of the above named contractor. I certify under penalty of perjury that all of the above information provided is true and correct. I further acknowledge that any untruthful information provided in this application could result in the certification being canceled.
I certify this on: 3:21 PM
Legal Entity Information
Legal Entity Type: Corporation
Name: PUBLIC RESTROOM COMPANY