HomeMy WebLinkAbout072-290-158s
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OWNER -BUILDER VERIFICATION
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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 major labor and materials for construction of the proposed
property improvement: YES UL NO ❑
2• I HAVE 06 HAVE NOT ❑ signed an application for a building permit for the proposed work.
3. I have con",�c};ed with the following person (F,rm) to provide the proposed construction: = ,
NAMVlAE: lc4wl L),1&r9i-a5 S id .
ADDRESS: /fav 51,_CI TY: ' !`V k4ivn rte_
PHONE:e�)O% 533-- 9,253 CONTRACTOR'S LICENSE NO. 4/-09679-
4.
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4. I plan to provide portions of this work,
supervise, and provide the major work:
NAME:
but I have hired the following person to coordinate;
ADDRESS: CITY:
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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:
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PROPERTYOWNER: i 1 N CCkT w pws; key5 k l
SOCIAL SECURITY NUMBER:
DATE:_ —q7
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.
OVER
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