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OWNER -BUILDER VERIFICATION
A:tencion Property Owner:
An "owner -builder" building permit has been applied for in your name and bearing your: -per,
Please complete and return this information at your earliest opportunity to avoid uaneoeWWIW
in processing and issuing your building permit. No building permit will ' be ias ied ivuit 8ds
verification is received.
1. I personally plan to provide the major labor and materials for construction of the proposed
property improvement: YES dl� NO 0
2. I HAVE® HAVE NOT 13 signed an application for a building permit for the pe+oposed VIG&
;. i have contracted with the following person (firm) to provide the proposedeoa m -
NAME:
ADDRESS: CITY:
A
PHONE: CON'TRACTOR'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: '
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:
NAIN IE ADDRESS PHONE TYPE OF WORK
SIGNED:
PROPERTYOWNER: e
SOCIAL SECURITY NU1MER: ,
DATE: 11j4— B 9
i'VOTF: This Owner -Builder Verification is required by Section 19831 and 198J2 oVdt
California Health and Safety Code. This verification must be c*NV&Wd Md
returned to our office before we are permitted to issue the perm&
OVER