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_ CITY OF DIAMOND BAR
Ii DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
2I8I0 Copley Dnve, Diamond Bar, CA 91765 PRESS
(909) 839-7020 Fax• (909) 861-3117 Building Inspection Hotbne (909) 839-7027 FIRMLY
BUILDING PERMIT APPLICATION wnweityotdiamondbancam bulldingudiamondbarcagov
JOB SITE ADDRESS / S-C;' P'e_
APN_ L T TRACT
OWNER
ADDRESS
L __42,�A S�� 2
241
APPLICANT _ TEL _n1ij! ;S jr— s;47
CONTRACTOR ��
ADDR �(-S`L" t ....
CITY __—ZIP TEL "-
ARCHIENG7
DESIGNER_ ..
ADDRESS
CITY ZIP TEL
OWNER-BUILOEROECLAeATI(M
I Moody ar ner under penCy of caury met I an exempt from the Cormactar's Saba Lkeme taw tar the maoon(s)
btdketPs beWw by Me Methanol I hate abroad next is the apphCetJe Iabal ISw�'=A. &miN end
Robakm Code Any net or county that vardike6 a pmrm to cwmins t and, Improva, domnhk ar rat, arty
Mmbm, prior aIra households.mmdme Me eppi[DOMfar tim pmMtm via a oigned sei"wfepl Aa 0r am
la k&MM pasaont a the "Id mofNetCw*a re Slob tics DUN(Cupla B) CommeNAm was Section
ci OMdoa 3 ofBm 9NIN Wm ROkUMM Cod01 or that he or sae is ammptham IlNmdre end!1e Mind for
meallegedmmpt:,n Any 00hutur, ofSumWn 7015 byary, llram!mapNrnft BUb#ats the aptheamto a dva barony
of W. mere man Eve %ndred dollam ISMI
of a wok
slWuTi not
mpMaeswim'red for We(Sec ,wlBnd UeeseenU fe
of qea Yres anew Un almemm 19 n Itapply t W Goner for We Becpan 7Cda, waymp and Pfarsonal B Dade The
Cammmcn'Statetfeawe Heydays na apply psNrY propertywhe,mmuag9mRm 'IXsoverrralefm46tdlaa
Oi Improves ire piopmty, provkbtl that m0 NxarememS ere rim Imerdetl IN ofiamd rIX ice q however thtl OAdna IX
nsead fir addwmhntat safe
at Comp BUar Ue DYwdt eJ:ltler will M000m9 M;rdBn aT pmwna thM lWsa MatbN:t
IX impmvetl far me G+MUoea IX BBItr}
(J4ea ownm offire pmpMty ere NdU.NBIY coMr�gt9 wigr #osnaea Coiron" to caaabuat#W Wa79m ISBaUon
7O4e ®ms-mn and FmkszWm Caff The CanVaMm' gate Vane taw doss not apP9 to an serer of property who
mksheor.mprbenns mdoon a(id W%rpommGa lgrlMB RmkCb Mth Ol Cei�tl DtlngBClor Rwer;Bm tilgw DIX�i$mre' Ste@
Lone, taw)
U Ism axwe lNam Unarmoften Metbntreelor'e Sete Ucame aw to me Mowing rmea*j
Data Ban -...
BY my derail OW l ecknadadpa UNIT rat my Personal msldeka M we l mum Move reallorep e< Nast one
year pr,Or a Wmpoon of the impmvemame taysrel by cols permll,I Maud hopoy an a structure met l fare MIR Us an
Owmar:Ma r it it has WI been mr"cW In Be monaty by licensed w erbodi I Understand mat a M of the
epPl ' le wee SOW 7044 Of the BuMn mid Pmfavaiane Code is aM*s Upon muem when bro appla ftom is
submmetlat,#*toyaWna Webslte ngpMvwi.gsda;e pPiRalew Mimi
UCENBEa C@nR MWS DECLARATION
1 hereby emtm W49Moody at pehury that I am lcensed order EynoonS at Chamber 9{mmmenanp wM Section TRIP
IX 71vlslon 3of qN BUStAM arm PMUSSione Code, and my alns, ISSIn full late pq i
LILENSECLASS LIC NO_�
iJP GATE t%INTPACrUpvtceil
WORKER'S CONMENSATM OECLARATWN
i HERSY AFFIRM UNDER PENALTY DF PERU.IRY ONE OF THE FOLLOWING DECLAAATIDNS
—In a 1e IMYNM a Ca Mfde of Consent to Siff-mi lot WOIkhrre CCmp WUW, as Wool by
13700 of ma LaMar Code for the performance et its work for whkh Nre Dwmfi # botudiff
I here and will manrch Wa%ere CompemaWn headrest, as requi Oy Semmll3700of me SBGXCode, he
fha "domrente of the wark for which DUB Parma is IsfUed My Warkera Cnmparvold" kalenN Career and
Pro" NUmtl ,
GflRtER f
POLICY NUMBER Q
(DESSEV04 NEM NOT BE CO.WLEMffTid: ('ISFDR ONE MRIDREDO 1AAS$100 ORLcESSI
IceNty a®tm lire padnnapi dw work hrwNrhtm.pera+n Isks,erl, i enNl rtamplvj arygetam In anY Irenmrmrote
hepeme roNem tc tice WOlmrs CampenseUw Lpwe of Cadonaa .4v1 spree ma: y I simuN arafem tame WDntp3
Cwgeawtiw Dots are IN SaCaon 3700 N d+e Lab W Cade, I shad Av s4yaCr empty wNn moss pmvh4vm
DATE APPLICANT
WARNWG Fella. to secure Worker's Compensation capa'eaB N orbs , vol shol Mateo so ampbyer M Mramai
Puma and Owl fines up to we hundred thoodal do Il UP00,003), an admtmn to me -aid W the Wmpamtion,
damages as provided V In soo kn 3708 Otte Igor MR hrmmst, amf eterrey''s fees
CONSTRUCTION LENCING AGENCY
I hsrebp Dann weer Denwty of pardry, taxer ¢cem M a CommuMon Loral Age" for we perfotnSnca of the *UN%he
won Res Be yod N Issued (Sea 3007, Qv C )
LENDER'&NAME
LENDER'S ADDS
m2ryihm"daremadmisepwsrelanand a'dm rem Gm aura IMand han`.he-areal mcomply witllaitDs end
ardP acid SlofO'.aW9remgn0 ma'#tdinatanaDW.tlOn. end hemtrt eJ'W(I29 reQNAamOtIVe9 CigeaOUmp fc
amp upon .. �iones tl proPerhkt tsPeatmn a
)
PtFOATTEE. tPyy
9IGNATDRE OF GATE ..................-
APPLICATION Dir pATEPfC# pf\I�'-(P`M
'r ,.
ISSUE DATE ( � + PERMIT# I R 13' �ac,10
TYPE CONST OCCGROUP
G1
Scope of Work
# DWEL UNITS,.........._ # STORIES
2.R �vr
# BEDROOMS
DESCRIPTION
$O FT
FACTOR PSF
ADJ AREAPIALUATION
BFRtADCVREM
I Oa"gobca oon
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uw. Poo0spa
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Commorceai
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Vahaatlnn
Act Aras,
QUANTITY
DESCRIPTION
FEE
UATicra
�I
�II
C
CONSTRUCTION
LOLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
_
31e. I7
SMIP
ENERGYPIC
..
ENERGY PERMIT
RETENTION FEE
PRE-ALT FEE
2
BASF
PLOT PLAN
ZONING CLEARANCE
TOTAL FEES
COMMENTS
I Oo , O 1
PyC .t PAID BY J�y (
RECEIPT# 35 p�7-q PAID BY �j_
VALIDATION _
VALIDATION