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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21810 Copley Drive, Diamond Bar, CA 91765 PRESS
,wy (909)839-7020 Fax (909)861-3117 Building Inspection Hotline (909) 839-7027 FIRMLY
BUILDING PERMIT APPLICATION wwwcityofdiamondbar.com buddmg*deamondbarcagov
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DWNEN-BUILDER DECLARATION
I MMIN rMmM under Priority of pa7ay fbffi I am enfrot Nan as Cmhaaa'D State Llmmo Law Nr the (mS (8)
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at the work, end de, srucame a not theorem r ffimted fa MID fSeeam 7044 DUNead am Walea9rons Cale The
Contractors State Lkeoee Law does nor mill town Moral Memo who thrtagh emptpYaas' mpasaMi omit, When
or Improves the proari Pwimd that the liff"erents a4 am miterded or offered foe aria d trnkoer in* burning or
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a mPnvetl la mr poorer asae )
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LICENSEE COMRAC'TOR'S DECLARATION
I honey aHnm under prom, of Many mat I am pmnSed ador"Sim at Cbpter 9 Mo robs" won Sane Tom)
at Chosen 3 of Does MzDi m had Woks9bns Coe, "I rl l�Is in Ad farce and effect
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WORKER'S COMPENSAP NN DECUJUUX41
I NEXIMAcFAM UNDER PENALTY OF PERARY ONE OF THE FOLLOWTW3 CEV"TtONS
I MAY and will mmMMM a Cr FICAN Of Cameo to Self MEMO for WakDr6 COMMMgm, am Punned by
$003700 of Me Labor Code far the pafamNCO at one work for wbdo Sae Mang b Issue
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Cr pafanraaane work fowNch Cra permitbisected My WpSxrs Coagemewnfimonce Camerad
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comma smM lathe Ware" Canaaasimen Laws a California And mPa drm m i Mmb basin NAW mfm WWWS
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APPL1 AN
WARNING Faiva to mare Maker's m cmeago B Made and Mali subACt an empbryer to UMti&
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CONS(RNCnOM LENDING AGNIMY
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LENDER S NANT ..
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TEE E{PPINT)
WNW G PERMIITEE DATE -
APPLICATION DATE F
ISSUE DATE `+
TYPE CO NST fAX�
— .... PICA
!C PERMITII
OCC GROUP
Scope of Work
A DWEL UNITS Dow t
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DESCRIPTION
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QUANTITY
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ENERGY P/C
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ENERGY PERMIT
RETENTION FEE
PRE-ALT FEE
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PLOTPLAN,
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TOTAL FEES
COMMENTS
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PIC PAID BY / VALIDATION
RECEIPT# S'1453 PAYCHAY J_ VALIDATION
WHITE — DaWmam Copy, YELLOW — Fineman, CODY, PINK — Assessor Copy