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OWNER -B UILDER YERIFICATION
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
v property improvement : YES Er . NO
2. I HAVE ❑- HAVE NOT Wsigned an application for a building permit for the proposed work.
3. I have contracted wi the following person (firm) to provide the proposed construction:
NAME:
CITY:
PHONE: b�� �-r CONTRACTOR'S LICENSE N(
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:
PHONE:
CITY:
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:
PROPERTYOWNER:
SOCIAL SECURITY NUMBER:
DATE: ,L jet' - 9f%
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.