State of California Secretary of State BUILDER'S AGENT FOR NOTICE (Civil Code Section 912(e)) (Office Use Only) Instructions: Complete and mail to: Secretary of State, P.O. Box 942870, Sacramento, CA 94277-2870. (916) 653-3984 NAME OF BUILDER_____________________________________________________________________________________ CALIFORNIA STATE CONTRACTOR'S LICENSE NUMBER ___________________________________________________ NAME AND ADDRESS OF AGENT FOR NOTICE _______________________________________________________________________________________________________ NAME _______________________________________________________________________________________________________ ADDRESS 1 ________________________________________________________________________________________________________ ADDRESS 2 ________________________________________________________________________________________________________ CITY STATE ZIP CODE SEC/STATE NPSF 800 Rev 04/2015 American LegalNet, Inc. www.FormsWorkFlow.com