This government document is issued by Contractors State License Board for use in California
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https://www.google.com/url?client=internal-element-cse&cx=001779225245372747843:tp8vx5o9m6y&q=http://www.cslb.ca.gov/Resources/FormsAndApplications/BuildingDepartmentReferralForm.pdf&sa=U&ved=2ahUKEwi2zZ7MhbrxAhXhpIsKHegYArw4HhAWMAR6BAgBEAE&usg=AOvVaw1iPdj1aA4x-tT8U3OfSHlL