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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21810 Copley Drive, Diamond Bar, CA 91765 PRESS
(909) 839-7020 Fitz (909) 861-3117 Building Inspection Hotline (909) 839-7027 FIRMLY
BUILDING PERMIT APPLICATION wwwcityotdiamondlearcons budding@diamondbama.gov
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JOB SITE ADDRESS 7
APN 11 LOT TRACT,.—
N OWER
ADDFLEESS
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CITY ✓IaM'0 ZIP TEL
APPLICANT TEL
CONTRACTOR
ADDR SS�( �S '
CITY
ZIP I TEL
ARCH/ENG/
DESIGNER IB
ADDR 3S
CITY ZIP TEL U iO-
OWNETI-BUILDER DECA TMN
I beauty affirm under onnady of III Met I am esempl tan Use Contact's Stab Lkeme Law lur N aumorod
Indicated below by Me teckmmrds), I have didaa nest t Me agemble denial Issues Mt 5, Bustle end
Prrledom Cafe: Arry city a unity M reguhm a permit to comMmL eller. Improve, dKndbh, or repan any
staclum, ptr to Its badwea, aim regWrm the a~ fear to person to me a singed etobamt Malin pwas
Is OmmWp Maul Is the provblpp of the CMmeMurs NO Uk Lew(Chmrer Ss Cammmtln0 wind Section
Mof OBslike ] n Me Bmtasp and Rolnelpo Cofel MMet be pone Is scamp tom IkamMa end iho ta4v for
Me alleged exemption My wtMbn olSmlbn70315 by Mryapplratfor a pemall erosion Me indent to emI penalty
of m1 tome then he hmMad mlbrs ((SW
U I, as ownerNMe property or In/ BmpNryBmwdh wagMm Meirsde mlrlpemffdM WA do Ual of MU pMmnB
of Me work, and the Owners IN rot Intended or offered for axle (Second 70W Sudden and Paabasbm Code The
Cotaxtars' Stale IA:eme gas does nt ahoy In an broar of pmpny win through employees' or personal effort, builds
or ImprMres Me preporbl, provned Met Me improvements am not Intended or oflened for sale It however, the Wming Or
Improvement Is sod wand n one year of compuon, the Pair -Bulbar ww lave Me burden of pmerg bill It was not built
or Imposed for Me purrpre M Bale) ,
U I As owur of Me property. am eanusiny competing with Ikenmd runbacon to bmeWn Me isolated (Second
TOW Budneea and Pmfesslom Code The Connectors' Stab Lkens, law does sal apply to an owner of popery wage
bulls p m Vwho lmpnmverson andmm mfordepmlemwdhatiwmtlCom orpuwMWu Cp Mrs'Stab
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U I arm eaelmt from IICM191 ra under Me Gont-wReS Same Liberia low for Me Mlowing mentally
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By my NgrMMs below I acymwbdge net, wept he my pemwel resioenoe In sAkh I new have ausund for at low am
year purr to compietlen of Me Improvements cavenad by Mb parody I mnrot legally sells stMtoau Mel I rem built m an
comer budder II It by bet men comMucbd In Its etimy by Ilremed cotmctors I unfendw1 Met a copy of Me
applicable Jew Secmn 70" of Up Malmss and Professions Code Is mai sm upon r¢emI wlwn MIs applcuMi Is
scomdbd or MAN Mlbwang Web site dip/www leglnno u gmhulas hot
LiGHM CONTRACTORS DECL nON
I beauty amrm under penalty nT penury tall and, Ilceread under posesipu M Chapter 9lmnmeming wit Spmn 7000I
of DYukdn 3 of Me Builders and PMBmIps Cue, and m/ Ilcame go In full force and effect
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LICENSE LiC NO "ndQ
DATE D(P� COMRACTD
WWUER'S COMPB MN DECLARATION
Y AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECIARATNNS
I tare and will monsoon a Cemdcale of Consent M Self -hour• for Yorkers Compensation, As porno by
Seum3700t Uwlabor Cade b MpedorrnanmofMaw for Nch Muspepolsaued
I revs and WI meMmn WpMra CampeseamnIrauMm mmguimdby SeMn3700t MeumrC •,for
Me pmforrname M Me work for which to min s romp My Workpron b er's Comeatdurpm Carder and
PMIcy Winn are,
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POLICY NUMBER l—
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CNIISTRUCTIONI GAGENCY
I beauty lam under pnalty M penury don Mom Is a Commodes Leading ApOrcy for Me perpmanse M Me wank for
sAkh this permit Is Issues (Sec 3097 Car C )
LENDER S NAME
LENDER'S ADDRESS
Immythat]havemad MIsapYllmmnandstate MatteatomIMomamnIem M IagmeMimplywIMMIeiyand
beauty oddeacre and o4b laws aulaOrl M building combucmn add hereto 0udwfm aupausonetim of MIs couty t
star on Me emve mOtloaed paopedylaMperyrses
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1113"EQFPERIAUEE GATE
APPLICATION DATE
ISSUE DATE
TYPE CONST
ERMITN
P/ M
OCC GROUP
Y!
Scope of Work p r 6LLD
N DWEL UNITS O STORIES
D D
N BEDROOMS
DESCRIPTION
SO FT
FACTOR PSF
ADJ AREA/VALUATION
SFR/ACH)MEM
Gara9a/Carpon
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Patlo/Deck
LL
PodBpe
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Z_
R"cot
9
Commmolal
Ed
m
velunt/on
_
Adl Area
QUANTITY
DESCRIPTION
FEE
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2
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f
CONSTRUCTION
PLAN REVIEW
l
ELECTRIC
S
PLUMBING
S
MECHANICAL
INSPECTION FEE
ISSUANCE
12LN llo
SMIP
�j• 3
ENERGY P/C
ENERGY PERMIT
RETENTION FEE
PRE -ACT FEE
BASF
PLOT PLAN
ZONING CLEARANCE
-91
TOTAL FEES
COMMENTS
a 9sI
P/C PAID BY
RECEIPTtyg—PAID BY V 0
VALIDATION
1 VALIDATION
WHITE — Department Copy YELLOW— Finance Copy, PINK —Assessor Copy
