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CONTRACTORS STATE LICENSE BOARD STATE OF CALIFORNIA
9821 Business Park Drive, Sacramento, CA 95827 Governor Gavin Newsom
Mailing Address: P.O. Box 26000, Sacramento, CA 95826
800.321.CSLB (2752) | www.cslb.ca.gov | CheckTheLicenseFirst.com
Building Permit Violation Referral
This form is to report any contractor who fails to pull a building permit for construction activity.
FAX completed form to: 916.255.4184
COMPLAINANT CONTRACTOR INFORMATION
PLEASE CHECK TO REMAIN ANONYMOUS CONTRACTOR NAME PRIME SUB
NAME DBA
AGENCY OR COMPANY NAME LICENSE NUMBER
STREET ADDRESS STREET ADDRESS
CITY COUNTY STATE ZIP CODE CITY COUNTY STATE ZIP CODE
PHONE NUMBER E-MAIL ADDRESS LICENSE NUMBER WERE EMPLOYEES PRESENT? YES
IF YES, HOW MANY?
NO
PROJECT INFORMATION (if available)
OWNER OF CONSTRUCTION SITE AND/OR AWARDING BODY PROJECT STREET ADDRESS
STREET ADDRESS CITY STATE ZIP CODE
CITY STATE ZIP CODE RESIDENTIAL COMMERCIAL APPROXIMATE DATE OF WORK
PHONE NUMBER
DID YOU NOTIFY THE LOCAL BUILDING
DEPARTMENT OF WORK BEING DONE WITHOUT YES
A PERMIT?
NO
DESCRIPTION OF WORK
FOR OFFICE USE ONLY
COMPLAINT NUMBER TYPE
CONST INV ORG PRTY DATE RECEIVED
MO DA YR SPECIAL PROJECT DATE STATE EXP
MO DA YR
ER
INIT
ASSINGED TO ER
MO DA YR
F Y
LICENSE NUMBER CLOSURE DATE CLOSED STATUS CHANGE
LETTER DISPOSITION
MO DA YR c c c c
SECTIONS VIOLATED c c DATE DATE DATE DATE
13I-29 Rev. 07/16/12 (page 1 of 2)