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' CITY OF DIAMOND BAR
I DEPARTMENT OF COMMUNITY & VELOPMENT 2YICE5
21810 Copley Dnve, Diamond Bar, CA 91765 PRESS
(909) 939-7020 Fax. (909) 661-3117 Building Inspection Hotline (%9) 839.7027 FIRMLY
BUILDING PERMIT APPLICATION www.cityaddiamoredbarcom 6mlding@i1mmond6arclegov
JOG SITE ADDRESS . 510
APN LOT TRACT
OWNER --S'p4c-c- if-AN'O
ADDRESS ��47��-Fc-e r-
CITY '54 ZIP�(Q&' TEL
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OWNER-8WUIE8 BECLA l[OR
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WORIa'RB CO"SATION OELARATER
1 NENSY AFFAM WIDER PENALTY OF MUM ONE OF THE FOLLOMNG DECL IFFIVI Ale
I al wd feel mead, a CwgfiMffi of Covert to Self many for Worker Compensation, as p2+Ned by
Sacco, 37Wa the Labe Code, far the p owassms of ma work br whim ifs memo Is named
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LENDERSSWrE
LENDER S ADDRESS
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PBIMIfTEE NAtAE
EXROTURE OF PUFF TEE DATE
APPLICATION �D�,,��AT//E� �'"_1 Z N �'� / PtC# PP. Cl''tla Z+
ISSUE DATE_lE"!., 111_PERMIT# �Fi t-Iff 2217
TYPE CONST // OCCGROUP
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COMMENTS
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