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. .._ CITY OF DIAMOND BAR c . .
DEPARTMENT OF COMMUNITY & DE4 LOPMENT SERVICES
21810 Copley Dnve, Diamond Bar, CA 91765 PRESS
(909) 839.7020 Fax: (909) 861-3117 Building Inspection Hotline (909) 839.7027 FIRMLY
BUILDING PERMITAPPLICATION wwwcitya(diamendbar.com buildingyddtamondbarcagov
JOB SITE ADDRESS "Jade �� / oa I am hq,,rEj.._
APN LOT TRACT
OWNER WlM '=..+a 4-(. A
Y ADDRESS �' i. 5914 Cn /., fines W a+t 1
CITY l J�', OOE' .e Fi..._ ZIP4141 — TEL
APPLICANT TEL 9'SI 27g' jrfC$
CONTRACTOR d%ossmna.J`
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ARCH/ENG1
DESIGNER
ADDRESS
CITY—ZIP—TEL
OK9s"ItDER DECLARATION
I N" wmms mar pelaky of psnuty too I am a Pt from the warwh 's S1Ma Lkwdw LOW for the r6E5on(et
IMkeaO Areas, by the dmN,merk(e) I lays Paced mM to DW applkz* ft m" fSedlm 7031 S. MxbM end
PmhWUrm Ccdr Arty dgrm MM that rKWM a OMM As kMUUC'L sifm, hgrale, OMI Nor meek, ANY
sGrmhm, prior to No hmmme Ws rebuires the eokwdto Ow permit to Bb a armed **a*t*ad he orsho
issue pureuentmehepoldeat the Contraction ObbLlee uwiehwWro)Comm n"Wlh Eeetlan
of DMemn 3 arum mm ihofedpN Coda)*rest ha ar ehsassempt hmniksnwm And the baslalt
tlw*aged eaemptlOn 4ryemmamolSkike7031 atgenY axrMteua eca Isis aeN9perellp
of AN Come am one hunhai dohme MM
0 AMamxnm o the sa unfuni he A wlmwed for NO nmmcmip , 80D 111 M PM Na OM Cuts
DDo
ai th oavork,d., OM me "Mom
DAN N Cot "" a offered "eala ISaCdwl 70dd, DUNeaas end P'Non," s Ode The
Cwroffiima'Sam Lkeass Lew does not eppryman awnerpl pmpedy wtm, INaugh empayeea wpsmltN minor Aldo
wlmpmms t Is ved wm, year
0 com mpmrom t morw fOt lMSMa hem AM d fw sek d howeaer, me MAamp w
Improvement la wlmin ono Yam M ¢mpadan Da Qwror Bulldm MG INro Don hudni d goNnp Dtel A was:ot a1M[
a lmDmsetl krsm M��le)
'., U1, as owpm of the in"". AN eulwWMY ow&amv*gh 1IttRm9 O,madwe moana§IrLttlm proJed (Se(.ibP
7044 Business and Pmfeta6+ie Ode The Ontreamrs Sam Lksn w Law does Pat appy by en awns of wopedy Into
j but do at lmpmves thxmon, a,a win wntraft for me prolwa th a gmnuld Ontraamr W`aurent to MNCwva:lam'State
Unow Lew )
U I eon mempt Rom Neroum m mCmbaeta'a Saw, Lkema Cow yes the%kAsd g MLm"
ads _- Sign
my MYsightestors bM3w l BMmeralls ffmt, euept for my pardsoral MOM In wash l must hate reddw for M that oro
year prior to Isvieibn of Ole IMpno m.aMe wove: by ON pemM I cmmd lately sal a sNldum that: hove win ae an
a ar-hW IT A ions not been cw,e0uctted In Hs HUMty by Ocmaad mtdtecmra I understand ma; s mpi, at the
eppiame low, SKIN, TO" of to &ddWr s an; tMBNssene Cade A e,awe low ounest when "a wolm� is
9ubm mMDNtaUbng Wen Na hlQl?NMx mgmuPMmr Mm1
LICENSED CDWTRACTDRS BFCW TION
I her" oRbm under Denehy d penury that I sn Ilpmaed under pmvaane of Chapte, G (aomnmmeng Wien Section Tom,
cl nwaan 9 dike B�raeaeid Pmmmbns lads ad mYit ie in NG lame antl BNmk
LRIOSECtASSe_s LIC NO I IQ ^'
W DATE 41 f� _ CDNTP%[OR 2 �$',$rys,}'—e /Z-Hwlu'tL
'SCOMPENSATIMN pECtARAI" /
1 HEREBY AFFIRM UNDER PENALTY OF FFANRY ONE OF THE FOLLOWING OEQUARATBNS
I have war wle mM,mmn a Ce=mte of CunaeM to Self We for WdkerY CompenBM m M alGNmd by
3700 d the Lollar CdN, for this pedf o(Ga walk six w"MN NoW is Imlad
Nmmandw atthlnvorcW aut%w mrBglared GtSKbd, 37G0 Mme tabor Coda, for
me padIXemaram mewalk lm onetime upmmtl8i�rod MYWorkere ma:mrce CenieraW
PoFry NPmbe! 8m
GARTER S`Zd& Brad
POLICY NUMGER
(MMCn NIt&EDNOTBEMWLEIEDWThEMWSFORCBERM9ED -LA%SIOCORUSR
Nodam Deamad p�rkmW58d DmpwsiorWN aPamneidN almthadmrpgerrypmpnem to toYamm
Comma mmsssof Seain3Moff eUsawdde,I SIN Algaid,mm l l should hamme wgmAmthe Wwkee
Cangtm2lbr,am'rearoaSaman 3Tt4dd,a kmaCme,IBhm'�fOdrweh Cortadywit, drsa prmYmone
OATE APPUCAN1
WMMNG Failure to seaura Worker a COMMMbm armage a Ua WNI sn0 SW o bPd An employe to
Isommea and #8 turn up 10 AN Mass# thousand ,Islas (510)0DO) la addam Or Don cst As DO mismsMtan,
tlemegss as prorroal far AnWW 3700 of the labor Code, camat ed adpmeyaion
CONBTADCTION LENDING AGENCY
i no"alArm under POW ar WM Got them Is a CwwKmt�P Land no Agency for IN part m at to walk for '.....'..
whic, INS Pemtlt Is Issued W 3097, Ow C)
LENDERS NAME
LO W4SADLWESS
I C:ft ti hags reed Cole applatem eW Mate mat the abare lnfid"Itn is oaredlsales mverpiywamOtitywo
o,mmnees and state laws mmum; to bulb; omMmNnn AN barony audmilm humNenlelvers M Me owny is
ends upon Die am'" mmamred pmpony tar iwonnu lap pmpasM
pEwnR��E
sl_i 'EBN'
!!ONEFUREDFANPATME DATE
APPLICATION DATE ,..o..l_IL
ISSUE DATE
TYPE OONST
PERMIT# _Ot
Pi
it - 01-9-ZI
OCC GROUP
Scope of Work
9 OWEL UNITS #STORIES
%BEDROOMS
DESCRIPTION
SO FT
FACTOR PSF
ADJ AREANALUATION
SFFVADDTREM
CBAmgetCmport
�
I Patlpynack
m"I
PaoVSpa
....-
9
i Commerdel
YatuaVan
Ad) Area
QUANTITY
DESCRIPTION
FEE
G
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P1C
ENERGY PERMIT
RETENTION FEE
PRE-ALT FEE
BASF
PLOT PLAN
ZONING CLEARANCE
TOTAL. FEES
COMMENTS
V7(a, (eZ
PIC PAID BY
RECEIPT e '% � PAID BY ..ap�.�/ �d�"_
VALIDATION _
VALIDATION
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