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CITY OF DIAMOND BAR
1 DEPARTMENT OF COMMUNITY& DEVELOPMENT SERVICES
21810 Copley Drive, Diamond Bar, CA 91765 PRESS
(909) 839-7020 Fax' (909) 861-3117 Building Inspection Hotline (909) 839-7027 FIRMLY
BUILDING PERMIT APPLICATION www.cityofdtamondbarcom buildmg@diamondbarca.gov
JOB SITE ADDRESS._-[_ %
APN LOT TRACT
OWNER
ADDRESS `771 LA•'eS NYt
CRY ^J 8.� ZIP TEL ,y� ���
APPLDCANT 1 ,jrlayJA vtA.+ti TEL -r-I3"7Ff7,f
CONTRACTOR /
ADDRESS
CITY Z1P , ('".%TEL 7/y 777 7 77'T
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL
OWNER BUILDER DEWRATWN
I hereby aman enter penoity a pnjmy Dal I am exempt tram the Comsaa's State Uptake Law her the reaSM(k)
indicted thelaw by the checWnarkiN I tare Macao next to The ammerible 9emn) Ittacbon MS. Beat, and
Profasmn@Cass, Any asyor county, that mquoa a permit to consWcl,alter, haPmad, Mmhah. or retalr, any
@truemw. Prbr m Ili hslmnw, abo Ieg11115a me apphcanl No pw Permdte fib a slated @btmrlenithat he or eha
as amended assawaM to the proralom of the Conceder'@ State Ucerso ON (Chapter 9) Oommercmg with Section
at Owswn 3 of pre BUwrdae died n'MBMraH Dodo] or that he Or AN, Is exempt been Ikemwa and me bass for
the alleged axwomr, Any MlalapM of Sespart MISbyany@Mli mfa@pemdtwolecs the appliad maUMpenafty
of reel we than fie hundred distal nSEOi
UI, a caner of the property, or my effo$WM NO W'aeka atheir @ob eompmsdbn, VA do V a0 of orL) porDau
of me work. and foe Ahatpwe is her W 0WW a spoke ipe Asia P3araM 7044 BLLala.® NO Fmtasbs Good The
Composed Stab Lkerda Lea Meg wit apply ma away at pmPeM who N oath ertpbfnp or Nnyandl Hirt Cain
a Impanel the propesy prowess pal the uposemens we rat Uundw or aRaed Its SM a hasaw r the wx" a
kagmwrcni sttld wMn one yeas canplobm Ne DwnV BUW WO here Nee Haden of PRAW) ft If area edf Mail
as a@roded par the olUpost a edb )
UI, a maPEr of As impact,, am exchaaely iBmmptwq wren ka d Canirxlaa M coca" IN prWKt mom
7044, Sesbwas eM Pmbssiaa CM@ The O rhaUma Snb LILa+3a Ww d099 not Apply to an 4 at pop" and,
buses agakineeBmremr.Not vrtWcmvacis Ber ea phdoos@ wide, a spowell cMnowpR to the Cmbaaars Stare
Law)
UIamNEmptfears Pope meLBdradorsShop Uu e taw In ft TodWdangmsmio)
Dale Sot
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I ampb Imply No prospects
r Nias#01 tad AN. a.
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bupAm N e has rat best re &W m as 4%Sg aY bceaad aobxoioq I aldoK'W sot a all/ lk Ua
ell impold seer No Eider 7On4 ar pN EksrWae and puto toMa COM a eeasabb Wan teaser Wlsn Dug apMbasm a
w➢rtnGed a m me IakaMng wepsae 1d4YWvn IapkyA CS pa7taiaw hbrtl
t]CU B CDN7AACFORS PEARBAIION
I tasty dam under penaay of perry that Ian PCaroN aaer pmWUasa GftaM 9lCawrba4a rem Bedpan 70M
of DrAft 3 at the Be amp NO Repo Cade wet my house
is �N AS some a d asset
LecoNsEcust; LID No 4 se
DAiE"f, /7 CON1W910R d.+...—..—.. �.
WORNFA'S COMP n NDEGMATNIN�—
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS
1 haw and We malmaln a Car thass, a Cwkamt to Soft opera let Worker's compensation, as piclaNd by
Seclbn 3700 ofthe Laba Code for the poefMmmfc@ of IN Week he whKh this parent is Issued I hate and way ma'.nts. Worker Canpanutbn insane@ as required by Sec ban 3700 of Use Labor Goan fa
UM 0er00130 f of pre week BY Wnkh this permit alalad MY Wofti a Campmaabon lnwrann Center One
Policy Wrote Ag
CARRIER jiL
PDLDY NUMBER
ITtffi SECTION NEED NOT BE WAAETIED IF THE Emery IS FDA ONE M RED NUA16 Sty ORUR
Iansythdhmeperbxnvaotent WaalarWiMpua pwnmshaed Ia�namrrptr//afypaaafin arcynanBr�wip
msw wwaaYe �na5ofl Lars qt Casltrna. And aaatiw N t etaldd crepes sdljst m@w Wwk®'a
ppfi4plsaSasm37(IOdme Lelia Codo t>iW taprMmtwrpeyMmRrosappiNua
DATE-APP IC"
WAMM y@aua m stone WOFWtl 5 d s WftWfA wen NOW tW" An ean"V be aknbW
pbnaTes and paid flnPs Ire to as I@adrea ft=W dDOm (Stye DOD) in edadM in IN apply pa #a
damages a pramAt tam e¢dmn 37ta d cap t�krapda W eresl afd amor ay'stma
COaMUCTIOM LiMOWGAGOMY
I hsaaf@than Upf paasy of PePhe thin f . is a (areirtw4M Luams; Agency far the pafamwaW by the weektat
paepMwtis89aad {S@C 39g7 CN CI
LENOEIrSWME
LENDERS ADDRESS
I GaRDy that I hate read e@sapWkathM and suite that me news biam rmen Is creed t egre@tocMyy Mpi ell Utyantl
atlaenD]9 and seem awe nodding to bunking comineCpM Had hereby aldhon7H Pgaas tat of tore CAM he
enter Wan me Band@ naldanml Woo" (er bEpe tlaf purposes
I tiryrrmal-)
F£PMDiEE NAME
SIGNATURE OF PERM114EE IRAIE
APPLICATIONDATE
// ���ap�� �P/C# r
ISSUE DATE f&zAV6_PERMIT# r� tG !0
TYPE COAST OCC GROUP
Scope of Work ............
0 DWEL UNITS # STORIES
# BEDROOMS
DESCRIPTION
SO FT
FACTOR PSF
AOJ AREAMALUATION
SFRaADDIREM
Garagnecarport
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PaHo D@ck
uw.
Pwvspa
2
Ro Root
Canmaclal
VaiMettort
Atli Area
QUANTITY
DESCRIPTION
FEE
Z�
G
S
3
t
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
h r
INSPECTION FEE
ISSUANCE
14,
SMIP
�7
ENERGY P/C
ENERGY PERMIT
RETENTION FEE
PR&ALT FEE
•I}A
BASF
PLOT PLAN
ZONING CLEARANCE
TOTAL FEES
COMMENTS
(n�
P V�
P/C PAID BY
RECEIPT tl PAID BY of/'
_ VALIDATION
__ VALDATION �•
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