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Attention Property Owner:
An "owner -builder" building permit has been applied for in your name and bearing your
signature.
Please complete and return this information at your earliest opportunity to avoid
unnecessary delay in processing and issuing your building permit. No building permit will
be issued until this verification is received.
1. I personally plan to provide the maj r labor and materials for construction of the
proposed property improvement: YES] NO[ ].
2. I HAVE[] HAVE NOT[ ] signed an application for a budding permit for the
proposed work.
3. I have contracted with the following. person (firm) to provide -the proposed
construction:
NAME:
ADDRESS: CITY:
PHONE: CONTRACTOR'S LICENSE NO.
4. I plan to provide portions of this work, but I have hired the following person to
coordinate, supervise, and provide the major work:
IV57U _IX
ADDRESS: CITY:
PHONE: CONTRACTOR'S LICENSE NO.
5. I will provide some of the work but I have contracted (hired) the followip&p.ecsons to
provide the work indicated:
NAME ADDRESS PHONE TYPE OF WORK
SIGNED:
PROPERTY OWNER:
SOCLXL SECURITY NUMBER:
DATE:
NOTE: This owner -Builder Verification is required by Section 19831 and
19832 of the California Health and Safety Code.
This verification must be completed and returned to our office before
we are permitted to issue the permit.
May 1995 2.26