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' CITY OF DIAMOND BAR
DEPARTMENT OFCOMMUNITY &DEVELOPMENT SERVICES
21810 Copley Drive, Diamond Bar, CA 91765 PRESS
(909)839.7020 Fax (909)861-3117 Building Inspection Hotline (909) 839-7027
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OWNER -BUILDER DECLARATION
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UCENSED CONTRACTOR'S DECLARATION
I hereby SBhm under pearly of purely mat I am learned under preWO ma of Chapter B (Commencing wan Sating 7DOO)
of Causing O of Me measumed;; and Ihhdyd and Code, and my license Is In�tAiell forest 90M of2;•L
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DATL/A_ CDNTRAC'TOR
WORKER'S COMPBISAnOR DECO ARATIONM
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LENDER S NAME
LENDEASADDRESS
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enter upon theme0 menkied property for IrMso +piapeam
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rUTUREOFPUtMffTU DATE
APPI.IOATION DATTEE
ISSUE DATE q f �1i Sw PERMI #
TYPE CONST
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OCC GROUP
Scope of Work
M DWEL UNITS a STORIES
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ELECTRIC
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MECHANICAL
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INSPECTION FEE
ISSUANCE
SMIR
ENERGY PIC
ENERGY PERMIT
RETENTION FEE _
PRE-ALT FEE
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BASF
PLOT PLAN
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TOTAL FEES
COMMENTS
x a y
PIC PAID BY
RECEIPT PAID BY �F"'�SGA
VAUDAMON
VAUDAnSe
WHITE —Department Copy, YELLOW —Finance Cop/ PINK —Adr e4im Copy