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-.__, CITY OF DIAMOND BAR
(� DEPARTMENT OF COMMUNITY ADE1 L.OPMEN'T 2YICES
21810 Copley Dnve, Diamond Bar, CA 91765 PRESS
(909) 839-7020 Fax, (909) 861-3117 Budding Inspection Hotline (909) $39-7027 FIRMLY
BUILDING PERMIT APPLICATION www.cityol'diamoodbar.com bmldmti g@Clueondbarca gov
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MM aOLDERDECLAAAMN
I N ever amen mied, pmety of perjury that I end dwarf fmm the CoMlwa Com, United Law for am andrombe
inommd brow by the CMCMergel, I Ian Pond rag to the mideabb howle} Charlimh Wul e, 6uwmm and
PMIBUI M Cam Any elh m dowdy that xUldim a mal W aDOMOL YW, Irma, dermild, or rmWdi my
dnwWn, edmw Na waded, aim implied ban untraidand tar the Detroit toCan a a4twd aWmmandVast toaw M
Is Dominion phamrmtm Me prwi lohn tithe COWOV oWa$fato Lkams Lana t(hordsrNo Comem dng with Reopen
7000 of Children of Wa EiMaea and MMWM OUR of -at he or ON 4@wm% from amnaaa and the DOE, do
the magedeaenadon Arcy vmatlonal Semon T03i St#anYeC#IkaM.iaf a permMeumecmmeepptcantm acivil mnoty
of not mod, am peel hwdtm doMa �1
UtafeMlmaftlm(Rapma}, or m7ampbyeeewlthwap wftkhole mmpemetml,*OOoUeadm U pmtlwm
at aw work, end to newrm a hot Imendm m olfew hm We Ismtlm 70" Earned and Prateaaem Coda me
cowa*a' State Lkmm tin nex Ugly man oanwrd Peabody War, vomi,empb7a9a' or Petmnal emit New
mkngpna tta plopedt', ptmmad awtflw ImpmnmmN MB nmintentea a ORemtlfw gale O iva2YPG Ue buddmq w
anPwondimt4 urn oho YamdmmPatlm tlr R+mN BdYbrwpi twig me burdendpavihq flwawe rho mill
dh knPhavad fwtlhe purphoed We)
Ui,maYbad nowdeOmpm'bremmmmwtihe potau iSmNanh
7044. am Pmmgwo Code Too C"B*M' SWUr Vorm Lew mm ml may m an CWnar d pmmrt{wo
WANar hapmnn tamon.adwammmehaINOrprejeem With alkbHedCotorwhiPromemtto toCmbacmm Smm
unrelated LAW)
U lath tan Oklahoma lower We Comecmms SMte Lkahwa how No tw fwkwng ML"B)
Of soft
BY my algm oAll acknowntoo W. esmet far my PaabW rWmncm in rich i moral ten=ldm he at ImSt mho
YM oft m of the lmpmmmems m by "a maned mnnpt lepwty and a Omm, than I near but eem
owner-bulmor a it no mr, Gan mnRt+clm m ho aMkmy by IUndletl mftcb>m I that a my Or Nor
mOPmda taw $bard 70" at tlw Buwnma end Ftotemmm Code la angaba own mere worn Me mpmeon is
ae"Ind w at Me fdtawnp Woo Bra httpmovi letem on pmr'oOn, Mml
LICENM CO TPACTOR'B DECLARATION
I hinder affirm under panty of perjury that I am flowed: how@ pmYNmna at Cha der q mormmem0 who Saelnn 7DO01
of D.vamn 3 of the Euslma and oddouxho Code, am my 110M on full mace and effeG
urvise D.Us UC NO t0 Iq L1,10
oATE 1O jI ,{ CONTRALTOR
WORMR'S COMPENSATION DECLARATION
I DIRECT APFRkt UNDER PENALTY OF PER W ONE OF THE FOUOwNO OECLMAnDNS
_ I ham and will ended a C4Nikabe of Domain to Sail mute nor Worl lI Comohnn , a pmNded by
India 3700 of Ma LemrCON, de the perMmmm of me wink imwMPN flea period Is 4med
I hen won Oil moment WpaeYs co n tenhourenm, in mpWmd by Settlm 37M of the Laden Come for
PdAl pedomm�mw are wprkimwAuh Idapemet ahmum MyWaxeta Cwrperamlan ImuahgpGankrand
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UNIS ECDDt7NEHt NOTBE ODMR E7YFTFf4SWS FOR ONE HAY OCLAAS$100 ORLESS)
I can" min Yw dte wokmrwahmapwnaraNNld, Imall nmampayam man marl went
banana wwadm rho WOWS Conexamom iewad QftrA . Ate NM tlw d I slots hatmm aaatm gw Wra*A's
OwgwMmhl=�ftINSaeam 3MO dt%LWv CDda I eW l.d? M mfMO wlm Olmb pabipre
APPtlCAYi
WARNING Fame m mom WWWG Compehomm WMW It wdmiui end oar moot An moeoff m Odmod
paamm and dial floe we m how WO" tmwam ftM i$IWM In mdaon m tlw conit of tin mapemamn,
dainepmm Pmmm la it msee voldl We amen CAe aaro w m o ntome7'e teed
CO6TRUCTION LENDING AMCY
I M14 WOM wwef Pefelp Of Cegloy Uri home Is a COnebactm LU"AOwY Elf the Padmn Of am NOR iw i.
WtdehtY¢pamet li l;matl (SeC 301 C)
L£NtER'S NAME
LENDERSAOMM
lamp andiho4T mhomeP"nichend emmIngco manImomaare h clones 1agreebmmMY ofhhnieayam
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mudy andamthowd rolrsq to bldimmiwwMOGan, a7d NembY BlatwtEe mDmmmmvebdma rcrxXym
abler upon aw amro mmtloiwtl proDedytalnapmtllot p:apmm
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BCdlA7URE OF PEAMTfE&� DATE
APPLICATIONDATE 71zk 1 1"i -PICA W.Nl—�9?t'nIB
ISSUE OATE�PERMIT#
TYPE CONST OCC GROUP
Scope of Work M, dp 8a0 S4 Pr d& iI -k't I,t
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# DWEL UNITS �# STORIES I # BEDROOMS 1
DESCRIPTION
$0 FT
FACTOR PSF
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PRE-ALT FEE
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TOTAL FEES I r t
COMMENTS
P/C yy PAID BY VAUDATIDN _
RECEIPT# _ 7�PAID13Y a/XSf+ VAUDATION _TLl
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