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OWNER -BUILDER VERIFICATION
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 major labor and materials for construction: of the proposed
property improvement: YES O NO�k
2. I HAVE X HAVE NOT O signed an application for a building permit for the proposed w6&
-3. I have contracto with the following person (firm) to provi a the proposed constriretlom' .` .• ,.
NAME: bo J�FFo 2 d . F i_6_,C rA , C -
ADDRESS: CITY:/�-�/S'
PHONE: ?
CONTRACTOR'S LICENSE NO. < `= A„;
4. I plan to. provide portions of this work, but I have hired the following person to coord'utiAw
supervise, andprdvide the major work:
NAME:
ADDRESS:"CITY:
PHONE. CONTRACTOR'S LICENSE NO.
5. I will provide some of the work but I have contracted (hired) the following persons to-pr9vide
the work indicated:
NAME ADDRESS PHONE TYPE., OF WORK =
SIGNED:
PROPERTYOWNER:
SOCIALSECURPTYNUMBER:
�
DATE:
NOTE: This Owner -Builder Verification is required by Section 198.31 and 19832 of Nie
California Health and Safety Code. This verification must be -completed acrd
returned to our office before we are permitted to issue the permit
� i .
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 major labor and materials for construction of the
proposed property improvement: YES[ NO[ ].
2. I HAVE[HAVE NOT[ ] signed an application for a building permit for the
proposed or .
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:
NAME:
ADDRESS: CITY:
PHONE: CONTRACTOR'S LICENSE NO.
5. I will provide some of the work but I have contracted (hired) the following persons to
provide the work indicated:
NAME ADDRESS PHONE TYPE OF WORK
SIGNED:
PROPERTY OWNER:
SOCIAL SECURITY NUMBER:
DATE: 2171�r
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.
Mav 1995 2.26