Complaint Form - Contractors State License Board
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1
2CONTRACTORS STATE LICENSE BOARD
STATE OF CALIFORNIA
|
Northern California:
Southern California:
Sacramento Intake & Mediation Center
Norwalk Intake & Mediation Center
P.O. Box 269116, Sacramento, California 95826-9116
12501 East Imperial Highway, Suite 620, Norwalk, California 90650
1-800-321-CSLB (2752)
1-800-321-CSLB (2752)
Complaint Form
NOTICE: INCOMPLETE AND UNSIGNED FORMS WILL BE RETURNED TO YOU.
DO NOT SEND ORIGINALS—DOCUMENTS RECEIVED WILL NOT BE COPIED AND/OR RETURNED.
Please attach COPIES of all pages of contracts (front and back), canceled checks (front and back),
invoices, advertisements, business cards, receipts, correspondence, etc.
PLEASE COMPLETE BOTH SIDES OF THIS FORM
1. YOUR NAME
last
first
middle
2. CONTRACTOR NAME (as shown on contract/invoice)
ADDRESS
number
street
LICENSE NO. USED, IF ANY
city
county
state
ZIP code
ADDRESS
number
street
PHONE WHERE YOU CAN BE REACHED 8 am–5 pm
city
state
ZIP code
(
)
HOME PHONE
EMAIL ADDRESS
PHONE
EMAIL ADDRESS
(
)
(
)
WHO PRESENTED THE CONTRACT?
1a.
I AM 65 YEARS OF AGE OR OLDER (optional)
SALESMAN ___________________________________________________________________
1b.
I AUTHORIZE THE FOLLOWING PERSON TO HANDLE THE COMPLAINT ON MY BEHALF:
CONTRACTOR ________________________________________________________________
NAME
last
first
middle
WHERE WAS THE CONTRACT NEGOTIATED? _________________________________________
PHONE 8 a.m.–5 p.m.
HOME PHONE
(
)
(
)
PROJECT INFORMATION
3. OWNER OF CONSTRUCTION SITE
4. CONSTRUCTION SITE ADDRESS
number
street
number
street
city
state ZIP
city
state ZIP
PHONE
PHONE
(
)
(
)
5. DESCRIBE BRIEFLY THE SCOPE OF THE WORK FOR WHICH YOU CONTRACTED (I.E. PAINTING, PLUMBING, CONCRETE, PATIO COVER, ROOM ADDITION)
6. CONTRACT DATE
7. AMOUNT OF CONTRACT
8. AMOUNT PAID ON CONTRACT
9. DATE WORK STARTED
10. DATE WORK CEASED
11. LIST YOUR ITEMS OF COMPLAINT (IF MORE ROOM IS NEEDED, PLEASE ATTACH A SHEET OF PAPER)
12. REMEDY SOUGHT:
FOR OFFICE USE ONLY
I
O
DATE RECEIVED
SPECIAL
DT STAT EXP
ER
ASSIGNED TO ER
TYPE
CSR
ASSIGNED TO CSR
R
N
COMPLAINT NUMBER
MO
DA YR
CNST
PRTY
MO
DA
YR
PROJCT
INIT
MO
DA YR
INIT
MO
DA YR
G
V
FY
LICENSE NUMBER
STATUS CHANGE
STP
CLOSURE
DATE CLOSED
C
C
C
C
DISPOSITION
LETTER
MO
DA
YR
DATE
DATE
SECTIONS VIOLATED
DATE
DATE
C
C
13I-15 (Rev. 03/04/11 page 1 of 2)
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