Fillable Complaint Form - Contractors State License Board (Page 2 of 2) in pdf

 Yes (If so, provide documentation with this form.)

 No

13. Have you filed in court to recover damages on this complaint?

14. Is this project a:

 Residence

 Commercial Building

 Other

15. Is this project a:

 Remodel

 Repair/Replace

 New Home

16. Was this contract:

 Written

 Oral

 New Home Purchase Agreement

17. Were there any change orders?

 Yes

 No

If yes, were they:

 Written

 Oral

 Both

18. Is your complaint:

 Abandonment

 Workmanship

 Other

19. Building permit obtained by:

 Contractor

 You

 Do not know

(Provide a copy if available.)

Name of building department: _________________________________________________________________

21. Did the contractor have employees?

 Yes If so, how many? ________

 No

 Do not know

Names of employees, if known: __________________________________________________________________________________________

22. Were employees, subcontractors, or material companies paid?

 Yes

 No

 Do not know

23. Were any mechanics’ liens filed on this job?

 Yes (Provide a copy if available.)

 No

If yes, by whom? ______________________________________________________

How much? $____________

24. What attempts have you made to contact the contractor?

 Unable to locate

 Personal contact

 Telephone

 Letter (Provide copies.)

25. Have you notified your contractor in writing of the issue in dispute?

 Yes (Provide copies.)

 No

26. Have you obtained an estimate from another contractor to correct and/or complete the project?

 Yes

 No

(If yes, provide copies.)

Amount $___________

27. Have you had the job corrected or completed?

 Yes

 No

(If yes, provide copies of the contract and proof of payment.)

Amount $ ____________

NOTICE ON COLLECTION OF PERSONAL INFORMATION

Collection and Use of Personal Information. The Department of

give us with the business you complained about or with other govern-

Consumer Affairs and the Contractors State License Board (CSLB)

ment agencies. This may include sharing any personal information

collects the information requested on this form to follow up on your

you gave us.

complaint.

The information you provide may also be disclosed in the following

Providing Personal Information Is Voluntary. You do not have to

circumstances:

provide the personal information requested. If you do not wish to pro-

• In response to a Public Records Act request, as allowed by the

vide personal information, such as your name, home address, or home

Information Practices Act;

telephone number, you may remain anonymous. In that case, however,

• To another government agency as required by state or federal law;

we may not be able to contact you or help you resolve your complaint.

 I would like to keep my information confidential.

• In response to a court or administrative order, a subpoena, or a

Access to Your Information. You may review the records maintained

search warrant.

by the CSLB that contain your personal information, as permitted by

Contact Information. For questions about the Department of

the Information Practices Act. See below for contact information.

Consumer Affairs’ privacy policy or the Information Practices Act,

Possible Disclosure of Personal Information. We make every effort

contact the Office of Information Security and Privacy Protection,

to protect the personal information you provide us. In order to follow up

1325 J Street, Suite 1650, Sacramento, CA 95814, or email

on your complaint, however, we may need to share the information you

privacy@oispp.ca.gov.

I declare under penalty of perjury that the information contained on this Complaint Form is true and correct to the best of my knowledge, and that this

declaration was signed at (city) ________________________________________ , (state) _________________ on (date) ___________________ .

I will assist in the investigation or in the prosecution of the contractor or other parties, and will, if necessary, attend hearings and testify to facts.

28. SIGN HERE ____________________________________________________________________________ DATE ________________________________________

13I-15 (Rev. 03/04/11 page 2 of 2)