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CONTRACTORS STATE LICENSE BOARD <br />9821 Business Park Drive, Sacramento, CA 95827 <br />Mailing Address: P.O. Box 26000, Sacramento, CA 95826 <br />800.321.CSLB (2752) I www.cslb.ca.gov I CheckTheLicenseFirst.com <br /> <br />STATE OF CALIFORNIA <br />•• <br /> <br />Building Permit Violation Referral <br />This form is to report any contractor who fails to pull a building permit for construction activity. <br />FAX completed form to: 916.255.4184 <br />COMPLAINANT COMPLAINANT CONTRACTOR INFORMATION <br />PLEASE CHECK TO REMAIN ANONYMOUS <br />CONTRACTOR NAME <br />5eterl & <br />XP.RIME , SUB <br />StaA C-Ek OA r\ ( <br />NAME ........" ...,,,c,...pr DBA <br />AGENCY OR COMPANY NAME <br />5 I - C_ bivi-iratt4.( -kailk Ptr <br />LICENSE NUMBER <br />STREET ADDRESS S <br />C. Fi a a el -hok <br />STREET ADDRESS <br />13 3 q "D .--r-0..e1 ):1---fa- P-oc‘J <br />CITY ,p, L <br />>1- 0 db2 A <br />COUNTY STATE <br />. (1 CA <br />ZIP CODE <br />ct52o 5 <br />CITY <br />(CV---o <br />COUNTY <br />5 1-C <br />STATK <br />C_Pt <br />ZIP CODE , <br />_53 <br />PHONE NUMBER <br />PI -16g - 0335 <br />E-MAIL ADDRES , <br />j \ A)0Ai SA u v‘or <br />LICENSE NUMBER WERE EMPLOYEES PRESENT? 12rfES NO <br />IF YES, HOW MANY? <br />JECT INFO MATION (if available) <br />OWNER OF CONSTRUCTION SITE AND/OR AWARDING BODY <br />G a. /or; <br />PROJECT STREET ADDRESS <br />cu5 -ro i ..4 i--ki2 (e <br />STREET ADDRESS <br />I q (z3 S . GrrJ '40 I ICIVJ <br />CITY STATE ZIP CODE <br />CITY -1.ir,&cA4 STATE <br />CA <br />ZIP CODE <br />q 5304 ESIDENTIAL <br />i <br />COMMERCIAL <br />ApP,ROXIMAT DATE OF WORK <br />lict r zo '24 <br />PHONE NUMBER <br />DID YOU NOTIFY THE LOCAL BUILDING <br />DEPARTMENT OF WORK BEING DONE WITHOUT <br />A PERMIT? <br />FOR OFFICE USE ONLY <br />D YES [)(NO <br />IAS/CRIPTION TOF WORK tis _mfi e s_ IA J.,7410 <br />ob-fra ;ri; r (AO- rer - _sj-c roliA 4 Ace <br />4-41614 4' opiAd tOW-6 _ rds Sec4 frk2.( <br />sq c ace ip-r <br />INV ORG PRTY ER <br />INIT COMPLAINT NUMBER TYPE <br />CON ST <br />DATE RECEIVED <br />MO DA YR <br />DATE STATE EXP <br />MO DA YR <br />ASSINGED TO ER <br />MO DA YR SPECIAL PROJECT <br />CLOSURE <br />LETTER <br />LICENSE NUMBER STATUS <br />DISPOSITION DATE CLOSED <br />MO DA YR <br />CHANGE <br />C C C C III <br />SECTIONS VIOLATED c c <br />DATE DATE DATE DATE <br />131-29 Rev. 07/16/12 (page 1 of 2)