13. Have you led in court to recover damages on this complaint? Yes (If so, provide documentation with this form.) No
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 led 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 notied 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 $ ____________
13I-15 (Rev. 03/04/11 page 2 of 2)2
____________________________________________________________________________ ________________________________________
________________________________________ ________________ ___________________
NOTICE ON COLLECTION OF PERSONAL INFORMATION
Collection and Use of Personal Information. The Department of
Consumer Affairs and the Contractors State License Board (CSLB)
collects the information requested on this form to follow up on your
complaint.
Providing Personal Information Is Voluntary. You do not have to
provide the personal information requested. If you do not wish to pro-
vide personal information, such as your name, home address, or home
telephone number, you may remain anonymous. In that case, however,
we may not be able to contact you or help you resolve your complaint.
I would like to keep my information condential.
Access to Your Information. You may review the records maintained
by the CSLB that contain your personal information, as permitted by
the Information Practices Act. See below for contact information.
Possible Disclosure of Personal Information. We make every effort
to protect the personal information you provide us. In order to follow up
on your complaint, however, we may need to share the information you
give us with the business you complained about or with other govern-
ment agencies. This may include sharing any personal information
you gave us.
The information you provide may also be disclosed in the following
circumstances:
• In response to a Public Records Act request, as allowed by the
Information Practices Act;
• To another government agency as required by state or federal law;
or
• In response to a court or administrative order, a subpoena, or a
search warrant.
Contact Information. For questions about the Department of
Consumer Affairs’ privacy policy or the Information Practices Act,
contact the Ofce of Information Security and Privacy Protection,
1325 J Street, Suite 1650, Sacramento, CA 95814, or email
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
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