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WBUtLDlNGPERMITAPPLICATIONwww.cityofdanmondburcom
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT 2VICES
21810 Copley Dnve. Diamond Bar, CA 91765p(E''
(909)839.7020 Fax:(909)861.3117 Building Inspection Hotline (909) 839-7027
FIRMLY
budding@admmondbareagov
JOB SITE ADDRESS -0
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OWNER NJ
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CONTRACTOR
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ARCH/ENG/
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OWNM-BUUER DECLARATION
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Nonni be" M UN d -WARrot. I have plead nod t5 the oppEcalka aomle) IBscow m331A, &Mind am
Cotle Any pity aemmtyfeet ladMiw a Revell CaNblNi, ✓rote improve, ar all arty
atmCtum, poor to its Warsaw, saw reWm On epplbatt to ato Pam IN a low smmwd that Ae a on
le VUMW PMORI to00 OfDay CanaealWOSaW U9axe UW(Chepar e) CommondN wit SKRon
YOM d OMAIN 3 of the auair end Profession Codal or met he a she I4 ommpt from lommure Ord tea on% Mr
the deda eaamm an Any vlWelke, ofSeldom 703f EbyAmy spolbpmfor a pemnit 4ubpctl the aliMnarrAb ac!yd panaey
of mor roan 0kn *fie funded doibN4 ISM
U 1, a Draw dfim Wapern. or my weAoyares amhamgea as RON wit compwuallm... ova do U all of orU whilmM
of the Mark, and ad eau um to not bbmlad ar dterpd for ogle (Suction 7044, eas.'nm and Pmfen" Cade fin
Cormanore'Simn Lkeaw law don Mt Way In as( ror of property arm, thmvpa amgayeea a periumm bead bode
a Improved the pmpeny, provided that the brom inaR4 are not founded or offend No was a nowarer the bdtdnp or
(ne"n ut la add eased Myear atcomgdon, the Deaver DOWN *0 menthe aedery ofpmdrg that it area My bun
Or tropmvatl W the wpm of cep t
U I, are oarran or m property Ron eaNu4Nety Wmadbg area Avoided Csmmebm to Mmtrud 04 dialect (Sadoo;
7044, DAIW A wb Rdeahre code fie Conbetiom' Saa Liamse Lew does Out eppiy b W Carton at property w9N
West, im t"demon, end wib W ract, for CA gttemwtth a lkeeed (Nmmo, Knout to Old 00 atbare' 9ft '....
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U i Pm aaenottmm enroaae amw taeCmtlector'e Don tkwwe par for the fonaemg MBMRe7
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By my m onna l arkruwkdpo mutorm: for my pamonm md0da b Onch l moat trove mum at law ab 1,
Year PAN, b MARPo m of the irammomem covered by role parts IVond legaPy Pail a 8"mure that l here ddk ea an 1
adde, it it FOR not dean comurned in us ard" by ikar6od camd m o I undemmnd troy a ropy at the
RWIM o oily, Sedin, 7044 of to end Pmmadons Code le WRImm upon mum wren NO apowdon 4
aUmlaadmaTPs bdpwinO Wed e�te htpaAVAw iapNne Co goo/cotes himi '..,.
UCENSED CO MiACTCR'B DECLARATION
tI mby affirm under p IT of oerfury mail I a-almmod Adder pmybedum of Owmat 9(ra,mteandng wan Secaon7
of Dlvixlon 3d l`N Oushow and Professlme Cadge, M my l':puma IS In on toted and affect
UCENSE CLASS �'� UC NO UA O
DATE-47= WNiAAL'f00. _dear Slo... YY
WOPoaN'S CO/A MA'TM iscutdal
I NOW AFFIRM UNDER Meal OF PERARY ONE OF THE F(ASOALNG DECLARATIONS
_ I M ab w/N matrtt m a C"lImw Of cownt b So Nature for Waker4 Compwmw eY proodad by
SWUM 3700 of the Ieatt Code b the perMnWkne of love army tar whin on Parm Is *W
I have and will malrdiIn Yearns CompenBatlon Insurance are (pointed p/ SWUM 37DO of the Labor Dodo tar
tMpafgnw dthswaktawff&hftpe PermtislwAdTAyWuaortl CompameDon NNumrNA CMmY Bntl
Pao Rumber�are
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POIJO NUMBER NN t_Ga VK—J--�.
(W*C't@9 NEED NOT SEDOWERM FTHE PBiMIT ISFOR ONE HARM MUAAS SURD ORUbq
I wono bermthe Pvefom lot are wrnkforaRct Da M" a betwo 1 email rvomboyary Motor In mry mnta Wb
1NWne Wo bpM Wfurk" Co rdala' atvi':awe of ONEMFA And POW Tat V. I gpdd bazma wnlem m Ta'AoawP
ComparaaMPrody"dSomon 3700 Of the Lamar Dark 100 IMawth rorr y Won Dona proneors
DATE APPLICANT
WARNING Fdlum to secure Worker's Can, peneal woul N unNwlub, orb ell stAIM an emmovr to Omdnd
pe ohms end Me TW vp b ere i AWW DentlMd dolam OPINION). In Women b the cols of the COmQemPpN!, '..
OMgm as Maided tx In sweet 3708 of Not laWcade,wisaw. find attorneys fee ''....
W NSTIIWTWa tH40tNO ALENCY .
I twity seam under peraty of Wory that mare Is a Conabadbon Lendbp Agency for the mrMRNnca of film Mark for 1i
tNNdi eaapa nA is hauad ISec 3097 ON C) li
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LENM SADDRBS
I UdaithaIireve r4.ffiI dare appNeatpn roofe mature above ImalnalomeAamw Iaomebechoingwthdledywm
tramutdon end able Iowa mpav to mudem@ comma on, and tomy,&two, mprrmmanve of dos Wmtyb
emaupkrtietabon mwmonM pmpertyiwlMpecUon PiPpaWe
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SICJIAIURE OFFS LRAMEE— DATE
APPLICATION DATE 53I l" 7 1171
ISSUEDATE WX-1 IN-1 PERMfttt
TYPE CONST
P/Cr
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OCCGROUP
Scope of Work
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DESCRIPTION
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FACTOR PSF
ADJ AREANALUATION
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QUANTITY
DESCRIPTION
FEE
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CONSTRUCTION
PLAN REVIEW
I a I .
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
2ai4a . 1 2
ENERGY P/C
ENERGY PERMIT
RETENTION FEE _
PRE•ALT FEE
N^ai. E3eVI
BASF
i • Cod,
PLOT PLAN
ZONING CLEARANCE
TOTAL FEES
COMMENTS
16 1
P/C PAID BY ../ VALIDATION ��
RECEIPT 0 TIP PAID BY"'A i15rS�'�j% Li+ALIDATION _ —gn3—
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