Fill and Sign the Civil Code 497298379 Form

NOTICE OF UNPAID COMPENSATION (Individual as Direct Contractor or Subcontractor) Name of Party Giving Notice:       Street Address:       City, State and Zip Code:       Relationship to other parties:       Name of owner or reputed owner:       Street Address:       City, State and Zip Code:       Name of direct contractor:       Street Address:       City, State and Zip Code:       Name of construction lender:       Street Address:       City, State and Zip Code:       Site of the Improvement: Street Address:       City, State and Zip Code:       Legal Description:       1. Name of individual laborer owed compensation:       Street Address:       Notice of Unpaid Compensation Page 1 of 4 CA Civil Code § 8104 City, State and Zip Code:       Total number of straight time and overtime hours worked on each job: Job A: Straight time hours:       Overtime hours:       Amount “Past Due” and owing:       Job B: Straight time hours:       Overtime hours:       Amount “Past Due” and owing:       2. Name of individual laborer owed compensation:       Street Address:       City, State and Zip Code:       Total number of straight time and overtime hours worked on each job: Job A: Straight time hours:       Overtime hours:       Amount “Past Due” and owing:       Job B: Straight time hours:       Overtime hours:       Amount “Past Due” and owing:       DATE:       Signature of Grantor       Type/Print Name CA Civil Code § 8104requires service of notice to the laborer; the laborer’s bargaining representative; construction lender, if any; and the owner or reputed owner. Notice of Unpaid Compensation Page 2 of 4 CA Civil Code § 8104 PROOF OF NOTICE DECLARATION (Civil Code § 8118) I,       , declare that I have served copies of the       (check appropriate box below): a. By personally delivering copies to: Name:       Title:       At: Street Address:       City, State and Zip Code:       On:       , 20       , at       am / pm. b. By Certified, Express, or Registered Mail Service, postage prepaid addressed to: Name:       Title:       At: Street Address:       City, State and Zip Code:       On:       , 20       Exhibit A attached hereto and incorporated by reference for all purposes See attached documentation provided by the US Postal Service or express mail service showing the date of delivery and the name of the person accepting delivery; tracking record or other documentation from express carrier showing attempted delivery or delivery of the notice; or, in the event of non-delivery, the returned envelope itself. I declare under penalty of perjury that the foregoing is true and correct. Signed at       , California , on       , 20 ______ . Signature       Print or Type Name ATTACH SERVICE LIST OF CERTIFIED OR REGISTERED MAIL WHEN RETURNED, OR PHOTOCOPY OF POST OFFICE RECORD OF DELIVERY OF RECEIPT. A notary public or other officer completing the certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. Notice of Unpaid Compensation Page 3 of 4 CA Civil Code § 8104 State of California County of ______________________ On ______________________ before me, ______________________ (here insert name and title of the officer), personally appeared ______________________ , who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. Witness my hand and official seal. _____________________________________________ Signature (Seal) Notice of Unpaid Compensation Page 4 of 4 CA Civil Code § 8104