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CITY OP DIAMOND BAD
DEPART ENTOFCOMMUNITY& VELOPMENTSERVICES
21810 Copley Drive, Diamond Bar, CA 91765 PRESS
(909) 839-7020 Fax (909) 861-3117 Building inspection Hotline (909) 839-7027 FAR Y
BUILDING PERMIT APPLICATION wrww.cAyoldiamodidbarcoin 1pitdmg*diamondbareagov
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JOB SFTE ADDRESS 21 3 2.- o U- r , 4nA. 5 ........ n u, CZ�
APN LOT TRACT
OWNSER
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CONTRACTOR '506,44
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aWNEN-BUILDER DECLARATION
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dew end w01 mannin Wmker'e Compenatlon Iraurence as required by Section 3700 of the LAW Cade for
the 0erfamadco of the work for which ma permit Is Issued My Worker a Compensation lnaurence Carder are
Policy Number are
CARRIER _ - ^a
POLICY NUMRFR Vsj ', nI
THIS Sam NBOMET BEWWU7W E Of POW 3FOR DhCWae DWlp5 ATOM OR LESS)
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PEN>VAM l
9puTUE DATE
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ISSUE DATE .+".�1D}11�t PERMIT#
TYPE CONST wN1IAe
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