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Attachment 3 - Building Permit RecordsTOWN OF LOS GATOS COMMUNITY DEVELOPMENT BUILDING PERMIT Permit ID/Type:B18-0254 Residential - Reroof Applied:03/27/2018 Work Description:T/O (E) COMP R/R WITH COOL ROOF COMP 700 SF Approved: Status:Issued Issued:03/27/2018 Address:435 SAN BENITO AVE Expires:02/24/2019 Owner:HOLTZ JAMES;BOWMAN BARBARA TRUSTEE 435 SAN BENITO AVE LOS GATOS CA, 95030 Phone:4083546970 Contractor:PETERSEN -DEAN INC 2228 JUNCTION AVE SAN JOSE, CA, 95131 Phone:408-667-5465 License No.:468117 Job Value:$4,000.00 Buildings:1 Total Sq. Ft.:700 Houses:0 Building Use:Dwellings Census #:434 Occupancy Type:R-3.1 Construction Type:V-B Total Fees $290.77 Total Payments $290.77 Balance Due $0.00 LICENSED CONTRACTOR'S DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Class _______________ Contractor License No. _________ Expiration Date ______________________ Contractor Signature _____________________ WORKERS' COMPENSATION DECLARATION WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. I hereby affirm under penalty of perjury one of the following declarations: ____ I have and will maintain a certificate of consent to self-insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Policy No. ____________________ ____ I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Carrier ______________ Policy Number ____________ Expiration Date ___________ Name of Agent ________________ Phone # ________________ ____ I certify that, in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Signature of Applicant Date Town of Los Gatos • Community Development • Building Division • 110 E. Main St., Los Gatos, CA 95031 408.354.6876 • www.losgatosca.gov • www.facebook.com/losgatosca ATTACHMENT 3 OWNER-BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the reason(s) indicated below by the checkmark(s) I have placed next to the applicable item(s) (Section 7031.5, Business and Professions Code: Any city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt from licensure and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): (_) I, as owner of the property, or my employees with wages as their sole compensation, will do (_) all of or (_) portions of the work, and the structure is not intended or offered for sale (Section 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who, through employees' or personal effort, builds or improves the property, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the Owner-Builder will have the burden of proving that it was not built or improved for the purpose of sale.). (_) I, as owner of the property, am exclusively contracting with licensed Contractors to construct the project (Section 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with a licensed Contractor pursuant to the Contractors' State License Law.). (_) I am exempt from licensure under the Contractors' State License Law for the following reason: ___________________­­______ By my signature below I acknowledge that, except for my personal residence in which I must have resided for at least one year prior to completion of the improvements covered by this permit, I cannot legally sell a structure that I have built as an owner-builder if it has not been constructed in its entirety by licensed contractors. I understand that a copy of the applicable law, Section 7044 of the Business and Professions Code, is available upon request when this application is submitted or at the following. Web site:http://www.leginfo.ca.gov/calaw.html Date _______________ Signature of Property Owner or Authorized agent___________________________________ DECLARATION REGARDING CONSTRUCTION LENDING AGENCY I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued (Section 8172, Civil Code). Lender's Name __________________________________Lender's Address _______________________________ By my signature below, I certify to each of the following: I am the property owner or authorized to act on the property owner's behalf. I have read this application and the information I have provided is correct. I agree to comply with all applicable city and county ordinances and state laws relating to building construction. I authorize representatives of this city or county to enter the above-identified property for inspection purposes. Signature of Property Owner or Authorized Agent Date Town of Los Gatos • Community Development • Building Division • 110 E. Main St., Los Gatos, CA 95031 408.354.6876 • www.losgatosca.gov • www.facebook.com/losgatosca TOWN OF LOS GATOS COMMUNITY DEVELOPMENT BUILDING PERMIT Permit ID/Type:P12-103 Residential - Sewer Line Applied:08/27/2012 Work Description:REPLACE SEWER LINE AND INSTALL CLEANOUT AT HOUSE AND PROPERTY LINE (WVSD 40565) Approved: Status:Finaled Issued:08/27/2012 Address:435 SAN BENITO AVE Expires:03/25/2013 Owner:HOLTZ JAMES;BOWMAN BARBARA TRUSTEE 435 SAN BENITO AVE LOS GATOS CA, 95030 Phone:408-354-6970 Contractor:DBA $15 SEWER AND DRAIN SERVICE P.O. BOX 26860 SAN JOSE, CA, 95159 Phone:408-995-6400 License No.:501065 Job Value:Buildings:1 Total Sq. Ft.:Houses:0 Building Use:Dwellings Census #:434 Occupancy Type:R-3 Construction Type:V-B Total Fees $117.64 Total Payments $117.64 Balance Due $0.00 LICENSED CONTRACTOR'S DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Class _______________ Contractor License No. _________ Expiration Date ______________________ Contractor Signature _____________________ WORKERS' COMPENSATION DECLARATION WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. I hereby affirm under penalty of perjury one of the following declarations: ____ I have and will maintain a certificate of consent to self-insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Policy No. ____________________ ____ I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Carrier ______________ Policy Number ____________ Expiration Date ___________ Name of Agent ________________ Phone # ________________ ____ I certify that, in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Signature of Applicant Date Town of Los Gatos • Community Development • Building Division • 110 E. Main St., Los Gatos, CA 95031 408.354.6876 • www.losgatosca.gov • www.facebook.com/losgatosca OWNER-BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the reason(s) indicated below by the checkmark(s) I have placed next to the applicable item(s) (Section 7031.5, Business and Professions Code: Any city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt from licensure and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): (_) I, as owner of the property, or my employees with wages as their sole compensation, will do (_) all of or (_) portions of the work, and the structure is not intended or offered for sale (Section 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who, through employees' or personal effort, builds or improves the property, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the Owner-Builder will have the burden of proving that it was not built or improved for the purpose of sale.). (_) I, as owner of the property, am exclusively contracting with licensed Contractors to construct the project (Section 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with a licensed Contractor pursuant to the Contractors' State License Law.). (_) I am exempt from licensure under the Contractors' State License Law for the following reason: ___________________­­______ By my signature below I acknowledge that, except for my personal residence in which I must have resided for at least one year prior to completion of the improvements covered by this permit, I cannot legally sell a structure that I have built as an owner-builder if it has not been constructed in its entirety by licensed contractors. I understand that a copy of the applicable law, Section 7044 of the Business and Professions Code, is available upon request when this application is submitted or at the following. Web site:http://www.leginfo.ca.gov/calaw.html Date _______________ Signature of Property Owner or Authorized agent___________________________________ DECLARATION REGARDING CONSTRUCTION LENDING AGENCY I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued (Section 8172, Civil Code). Lender's Name __________________________________Lender's Address _______________________________ By my signature below, I certify to each of the following: I am the property owner or authorized to act on the property owner's behalf. I have read this application and the information I have provided is correct. I agree to comply with all applicable city and county ordinances and state laws relating to building construction. I authorize representatives of this city or county to enter the above-identified property for inspection purposes. Signature of Property Owner or Authorized Agent Date Town of Los Gatos • Community Development • Building Division • 110 E. Main St., Los Gatos, CA 95031 408.354.6876 • www.losgatosca.gov • www.facebook.com/losgatosca TOWN OF LOS GATOS COMMUNITY DEVELOPMENT BUILDING PERMIT Permit ID/Type:B03-000239 Applied:04/16/2003 Work Description:T/O 3 LAYERS R/R 50YR COMP SHINGLES CLASS A 1700 SF Approved: Status:Finaled Issued:04/16/2003 Address:435 SAN BENITO AVE Expires:08/20/2003 Owner:HOLTZ JAMES;BOWMAN BARBARA TRUSTEE 435 SAN BENITO AVE LOS GATOS CA, 95030-5304 Phone:408-354-6970 Contractor:PETERSEN - DEAN INC. 7980 ENTERPRISE DR , , 94560 Phone:(510) 494-9982 License No.:468117 Job Value:$4,250.00 Buildings:1 Total Sq. Ft.:0 Houses:0 Building Use:Census #:434 Occupancy Type:Construction Type: Total Fees $173.90 Total Payments $173.90 Balance Due $0.00 LICENSED CONTRACTOR'S DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Class _______________ Contractor License No. _________ Expiration Date ______________________ Contractor Signature _____________________ WORKERS' COMPENSATION DECLARATION WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. I hereby affirm under penalty of perjury one of the following declarations: ____ I have and will maintain a certificate of consent to self-insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Policy No. ____________________ ____ I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Carrier ______________ Policy Number ____________ Expiration Date ___________ Name of Agent ________________ Phone # ________________ ____ I certify that, in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Town of Los Gatos • Community Development • Building Division • 110 E. Main St., Los Gatos, CA 95031 408.354.6876 • www.losgatosca.gov • www.facebook.com/losgatosca Signature of Applicant Date Town of Los Gatos • Community Development • Building Division • 110 E. Main St., Los Gatos, CA 95031 408.354.6876 • www.losgatosca.gov • www.facebook.com/losgatosca OWNER-BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the reason(s) indicated below by the checkmark(s) I have placed next to the applicable item(s) (Section 7031.5, Business and Professions Code: Any city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt from licensure and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): (_) I, as owner of the property, or my employees with wages as their sole compensation, will do (_) all of or (_) portions of the work, and the structure is not intended or offered for sale (Section 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who, through employees' or personal effort, builds or improves the property, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the Owner-Builder will have the burden of proving that it was not built or improved for the purpose of sale.). (_) I, as owner of the property, am exclusively contracting with licensed Contractors to construct the project (Section 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with a licensed Contractor pursuant to the Contractors' State License Law.). (_) I am exempt from licensure under the Contractors' State License Law for the following reason: ___________________­­______ By my signature below I acknowledge that, except for my personal residence in which I must have resided for at least one year prior to completion of the improvements covered by this permit, I cannot legally sell a structure that I have built as an owner-builder if it has not been constructed in its entirety by licensed contractors. I understand that a copy of the applicable law, Section 7044 of the Business and Professions Code, is available upon request when this application is submitted or at the following. Web site:http://www.leginfo.ca.gov/calaw.html Date _______________ Signature of Property Owner or Authorized agent___________________________________ DECLARATION REGARDING CONSTRUCTION LENDING AGENCY I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued (Section 8172, Civil Code). Lender's Name __________________________________Lender's Address _______________________________ By my signature below, I certify to each of the following: I am the property owner or authorized to act on the property owner's behalf. I have read this application and the information I have provided is correct. I agree to comply with all applicable city and county ordinances and state laws relating to building construction. I authorize representatives of this city or county to enter the above-identified property for inspection purposes. Signature of Property Owner or Authorized Agent Date Town of Los Gatos • Community Development • Building Division • 110 E. Main St., Los Gatos, CA 95031 408.354.6876 • www.losgatosca.gov • www.facebook.com/losgatosca This Page Intentionally Left Blank