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9
- _ — CITY OF DIAMOND BAR
F DEPARTMENTOFCOMMLTNITY& V LOPMENT RVICES
21810 Copley Drive, Diamond Bar, CA 91765 PRESS
(909) 839-7020 Fax: (909) 861-3117 Budding Inspection Hotline (909) 839-7027 FIRMLY
` ewe' BUILDiNG PERMIT APPLICATION w .cityotdtamoodbarcom baddmggdiamondbarca.gov
JOB SITE ADDRESS f C0,1 G L*'t a i hi
APN LOT PACT _
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OWNER
ADORE S
CITY w7 STEL
APPLICANT r
CONTRACTOR
ADDRESS Ia D G7 L S
CITY ZIPOfWEL Cb 2L 'SI —
ARCH/ENG/
DESIGNER
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ADDRESS
CITY ZIP TEL
UWNER-91ALOER DECIADAnOs
I lumay aroma ummr penalty it, away that I am eland tram the Cwtrada's Sham Umam law lot the ran M
iMlcomtl brow by the onmkmovii I taae pied and m the appliance aarMis ($&Wn 70315, Suslmm we
pvl"me Coda Airy city at wordy that ra*kn a p tto conmot am, bmrove. denwlah, or repair, say
Nowtun, prior to lm l�,, elm to im go eoiwml for lM permit to Me e$latest efatement that he Or No !
iu llawwed pwxmntto the pm*lom of the Catbactat'e Starts, Uw o Law (ChapW91 Cammmcing aMl Smtlm '..
7mOm Dlvalm3af Owl and P,u Ions Code]ormi a`gre is eeemplbamioamamardtne sale for
twaliffeadeser i Awfv!aI jocfSeMaP7031 Say enyeppaaam Tw apwma 9uoje�taa opptlmtm BalMl Gamlty '
of not mar than ova hundred doiors Dayi
UI. as dwawr athe property, or MY employee with wages as that ham wmpensamn, Will do LO all of V U marl I
of fAe wale and dt sbumi In nor ant red in Mferm for vain (Secyan 7Gi4, Buanme and PMesd m Code Thd
Camraztwa' Swle James taw dxa not aopiym an owmr at properywtta, fkau%h empwyeas or persarel effort bulb
w Impmaes Tha wowdly prov rid trial the NpmYemaas are rwt II tend!e ordmmd Tw agile If howevar, Us Names Or
meffurn'^wm is Ron want am year 0 oon*Wn the Ramer aulldarwpl hawtW burden of wmi %that hand PO! halo
or Improved fwpw purpose at ink I
U 1, m owner Of ftw VO", am e4DlNWveN CW*aCUN with egmraed CaNectom to qumb,rci me PMIWI DIKUM
7044, Business and PrUa Wow Coact The Llmnm Law does hot soon to on maser it properly who .'...
buhaS Or Improves awfmn, so who Oadano fair #w "" wM a Urtawm Cantramor purelmr!t DO the COMMM' cuts ''..
Umnm Law)
L) I am azempl from ecenm#e writer ma QPkdNrw'9 stem Umisa now ia#afoilowing rea5 RM
Date 4on _..... .....
BY "%a%mow baow l mWmwadpa tlwt axoapl Prany Personal reamerrs it wiect l -due have named toot Pepsi .
year prtvWp p%Uonof the Imprwrem"f and Uthin permit 1 ummlogWOlamuuiurethatI havebtdtaan
warm blow If 4 has rat been mmmucWd in ha own by bootees Dam?emora ! Ornament that a body of to '
scallops Nw. Samoa 7044 at the Buarwm and ProK 's Code Is ovaimble ow Rq"- wean thin appemOm is
mbmiaed Or 4Ord oweraO3 Web ate intn"W" Ielado ca gm/CNW And
LICENSED CONMACNR'S DECLARATION
i finally affirm undo, Density of per;ury, that I am Roomedands wmllne by Clwpmr 9 (oxfordi YW. Saoat ]WO)
a O:Yom 3 of the Business Ions Pmtesi Code, wit rry kern Is Is fur farm and ebmi
UCME cAR ! !
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DayDATE _t CQNiRdOfOR , h2 _j R.C. � '
WDRI®t'S COMPENSAnON DECLARATION
i. HERESY AFFIRM UNDER PENALTY OF PERJURY DUE CFTHE FOLLOWING OECLNNTRNIS
1 nave alit WO nmeta n o Co Mwme of Cream In Self Insure OW Wakw s, Cam irshr m no prormad by
�5xitln 3700 Of and Lebo Code, fir the pedanw,xs Of On wont Us Walsh thus same Is "ad
_ I hard Ord win mNMeh Woram's Commmaft bmuwrica At required by Season 370001 Am tabor Code, for
the perNr^, .m G4tw Waefar wniCN7I30OMft DMmj No WO.. is to !m m.orner antl
Polley Nampe'a 1
CeAmEfl r r EJ
POLICY NUMBER
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(THIS SEL'i NEED NOT BE ,W F'Ok PERMR 6 FOR 0M KSM DOLLARS$100 OR LESS
cem7patwpwparmrmMm olmewakfe u4whthwpema w Issuatl Ishii!. mi wnpkrymywrsn In my mow#: row W
Demme vois WOw Wakar's Commn=M Lava of DationaAntl ogres Nardi tern.-m arbfeclWd'o Wakm's
Compwvlmhn wawdMam SacbM3700 wtlw LabaCade 1 shdi mYMwth cgnpk'rdmilmm waadeom
DATE APRICANT
WARNING FaIIM ill wows Wwiara Co mpemmbo coverage ra Irel iW, and site SubjeC m ortterisr to cdmmel
%asides. and gMl Iran Op In we Hundred thousand dNam pa, 0040 i. In adaltan to Gas coat of no, aUnperaatlon,
dma%28 es provltled far f dacfbn 3t08 U:tw INOnroal imams, and adamey'¢mea
9014TRUCTION LMlitG AGLIV
I homby affirm under penalty of pal met um is a ConmruehM Limd!ry Agwfey fw the perlmexe of Ow work for
this mrm:!t'.s Issued (Sec $097, CM Ci
IENUER$MSME
.....
LENDER S ADDRESS
I fai that I hero read mliapoleoon and Wain Veri rive Information Is core:[ i %ream COmpy war ail airy eat
aunty"narcm am come laws adding to aaMfg Palmer a+, awns hereby emhndm fepfwa #os atthls cwaaYW
Baer uponnttq above mwterad pgparty for msperan pidpaoas
I clgq 7/ Elf S. �J'I
PRIATTEE NAME (PION 11
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SMaKANRE OFP DATE
APPLICATION DATE P/C# { \Z �'i aifdm\
ISSUE DATE \> 1 w�i ul I N—IIII'ERMIT4 Vi di!] -_ q_kau,� 'I
TYPE CONST OCC GROUP
Scope of WorkTepip;ai
tat ew(7
#OWEL UNITS Alf STORIES At BEDROOMS
DESCRIPTION
SO F7
FACTOR PSF
ADJ AREAIVALUATION
SFFVADIVREM
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Dwage.+ccwpart
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PaaBpe
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Vatnetlom Ad) Area
QUANTITY
DESCRIPTION
FEE
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CONSTRUCTION _
PLAN REVIEW
ELECTRIC
PLUMBING zil "11,\G3 . a0
MECHANICAL
INSPECTION FEE 1�
ISSUANCE
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$MIP
ENERGY PIC
ENERGY PERMIT
RETENTION FEE
PRE-ALT FEE
BASF ..... .
PLOT PLAN
ZONING CLEARANCE
+�
TOTAL FEES
COMMENTS
PIC lt PAID 9Y ,.++w___/—,VALIDATION
RECEIPT#y��4)j_ PAID'®T VALIDATION
WHITE—Oapwtmwn Copy, YELLOW—Rerwash Copy PINK—Aseeesar Csspy