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CITY OF DIAMOND BAR
DEPARTMENTOFCO UNITY& VELOPMENT SERVICES
21810 Copley Dnve, Diamond Bar, CA 91765 PRESS
(909) 839-7020 Fax (909) 861-3117 Budding inspection Hotline (909) 839"7027 FIRMLY
"�'� BUILDING PERMIT APPLICATION www.cityofdismondbarcom building@Wdiamondbarea.gov
JOB SITE ADDRESS L1...._�'t�<
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CITY ZIP TEL
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DESIGNER
ADDRESS
CITY ZIP TEL
OWNER-BIALDER DECLARATION
I WOW anm amw amary of perjury tha I am maBmpt h m Mw Cmlracmr9 Sala I WAN Law for mB Assays)
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LICENSED CONTRACTOR'S DECLARATION
I hereby anlm arch Manny of INJUry Mat I am keread antler pmnalaa at CKVW 9 (wrmendro wM WW 700U)
of OMam 3 of tie W*M ad Avlawlan Code and mY llcaee is In W low and Matt
LICENSE CLASS Ur NO
CONTRACTOR
WOPARS COMPOISATIM DECLARATION
i HEREBY AFFAM UNDER PENALTY OFPERA RY ONE OF ITT FOLLOWNG DECIAPAR016
_ I hate a'd mIi Imidea a CwMkMa of Caent to SAY hale fa Warfare Compensation, As pmAke fry,
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0%SECTION HEAD NOT BEOJMRkTEDFTHE MRAT 6FOR ONE KAVA OBIA6411001 OR LESS)
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COSFRUCTMN LENDING AGENCY
I hereby OMM uma peaty a peryary Mal Math a s Ca slauGan Lading AgWAY for me wa,MONG of m0 wfk Ia
WAIM"a 0"R 5 Am"(Sw 3097 Cn CI
LENDER B NAME
LENDER'S ADDRESS
I ceaN RANI I have And this appAMW ad Gala Mat ma above W%rnMW 5 Wrrect I apse to aarsory wM ad CAT aid
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aaa WdrRMya+yetgl8malMa�Wgiafy Ta fkaDael /^
PERM N}E NAMERPONiI}
Twdior PmMTTIFE DATE
APPLICATION DATE - ! " — I
ISSUE DATE y' aolt'S PERMIT#
TYPE CONST
P/Cif
V'W:k lam"
OCC GROUP _.........
Scope of Work
a OWEL UNITS # STORIES
N BEDROOMS
DESCRIPTION
SO FT
FACTOR PSF
ADJ AREANALUATION
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PLAN REVIEW
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ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCES,
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SMIP
ENERGY PIC
ENERGY PERMIT
RETENTION FEE
PRE•ALT FEE
....t?Ca
BASF
PLOT PLAN
ZONING CLEARANCE
..........
TOTAL FEES
COMMENTS
PiO PAID BY VAUOATLON
RECEIPT# QL.SQ5 PAID BY $$ eCIIDATION
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