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CITY OF DIAMOND BAR .-
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21810 Copley Drive, Diamond Bar, CA 91765 PRESS
,,, , (909) 839-7020 Fax: (909) 861-3117 Building Inspection Hotline (909) 839-7027 FIRMLY
'81e` BUILDING PERMIT APPLICATION WwRvcityofdiamomfiarcora budding@diamondbarcagov
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CONTRACTOR
ADDRESS I I Li U S. C a N r CA 12 o
CITY ZIP 94J .' TEL � , l?
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DESIGNER
ADDRESS
CITY ZIP TEL
OWNER BWLDPR DECLARATION
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LICENSED CONTRACTOR'S DECLARATION
I hereby amrtn remer W34 of What, Nat I am (moment! antler wwbimmi of Owider9 to irmendnO with Section 7000)
of Diflaw 3 at the Rlenes and Andesalons Code end my liietenaK In NN hemil enad e�na—a-
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ESP DATE. if f) (f_�(e CONTRACTOR t24 V., 0
WORKER'S COMPENSATION DECLARATION
I EAENY AFFIflM UNOEA PENALTY OF PERIURY ONE OF 71E fOLLOWING DECLNNTIONS
1 new aM w01 malnmN a fadMam a Ceeaaa ID Sa6Lmue br Wakara CanmmeBOm, as PMV" by
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_ I haw and MAmahRBin Waker'arwwNansatlmNwmnce as mquha l by section,3700 a the Labor Code to
the fer omRnce of the week for which her pemai Is moved My Waka's ConformaOM 4'Apmna Cartier and
Poky Nomba the
CARRIERS-trl�r� �vv na
POLICY NUMBER
(THIS SECTION NEED NOT BE COMPLETED IF THE RAW IS FOR ONE HUMFED DDJAFS $100 OR VSE
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WAWdtAI Failure f, attain Worker's Canpasaim coverage Is unkefd anal Pat we)eit w w olonr In Oadnd
WOW wed den nPRS a to we hundred Cpu9nd doles (SIO6o001 in adOw b the Cat of OM taipans"an
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CORSEMCIWN LFHmIG AGENCY
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PEAFRTIFF tUWh "
SSt{A PERMtiTFF DATE
APPLICATION DATE i I J 1$I f ( PltCt7�
ISSUE DATE li a✓ 1&1(o PERMIT, �pFtt +Y — 2? T—L
''.... TYPE CONST OCC GROUP
Scope of Work
A DWEL UNITS A STORIES A BEDROOMS
DESCRIPTION
SO FT
FACTOR PST
ADJ AREA(VALUATION
SFR+ADDWM
Gartradic., inp-
.
Patksr0eck
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Ppoespa
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Roor
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Canmercrei
Vatuerdom Adl Area
4UANTTTY
DESCRIPTION
FEE
(
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hi A,V
CONSTRUCTION
PLAN REVIEW
ELECTRIC NO
PLUMBING
MECHANICAL
r
INSPECTION FEE
ISSUANCE 1`2
SMIP
ENERGY PAC
ENERGY PERMIT
RETENTION FEE 2, co
PRE-ALT FEE
BASF
PLOT PLAN
ZONING CLEARANCE
,{�
TOTAL FEES 'r'r
COMMENTS
PIC }����PiiAID BY �a ++' VAIDATRIN
RECEIPT ^JFYiT{ PAID BY r�s1 £i VALfOAMON Aj
WHITE —Department Copy, YELLOW —Firarge Copy, —Asaesaa Copy