HomeMy WebLinkAboutC&D FORM AND RECEIPT - FIREPIT DR-
City of Diamond Bar
)IAMONR.l~~ Construction & Demolition (C&D) Debris Plan
.. Required for all covered projects, 1,000 sq. ft or more. The deposit shall be returned, to the applicant, without
interest, in total or propo1tion upon submittal of proof that no less than 75% of the C&D was diverted.
Use of unauthorized waste haulers may also result in forfeit of the deposits.
Receipts and weight tickets can be submitted to: greendb@diamondbarca.gov
Deposit (per project): $50.00 for each estimated ton. but no less than $250 and not to exceed $5.000
Complete before obtaining a building, combination or demolition permit.
Submit this form and your deposit to the Building and Safety Division located at: 21810 Copley Dr. Dlimond Bar, CA. 91765
Applicant Contact Informatio : t / \(,,, ,1/; I t7 S -z._. t-/
Name S S: Title f M. Company {}f,i R:!ah-b,,
Addres ~=-.L..L.-l.J_-...L.J~-:J-ZJ_~~-~~--City VA:l4', t.Jt'~tat~ Zip ~~dJ,-
~ Q.,, :c .~
Project I ormation:
Permit No llev IS a Self Haul
Project Address --"~.L--1---~~~~J._ ____ ,,__ ________ Zip <J'(7 h £
Project Type: D New Construction D Addition/Alteration
Building Type: D Commercial ~esidential
Estimated Square Feet '1.-£ (.)0
Estimated Start Date / / / £ / 2.,{,
Estimated Completion Date / / ~ ) / -Z, Jo
Demolition
TO BE FILLED OUT BY CITY STAFF
"C&DDepos"t"Paid$ a s'O· 0 t7
Staff Initia ~t=.,__ Date Paid l -l S-7i27-b
Fill out the table with estimated quantities in tons for each material that will be generated by your project. Note: A + B = C
Material Type
Asphalt & Concrete
Brick/ Masonry / Tile
Cabinets, Doors, Fixtures,
Windows (circle all that apply)
Cardboard
Carpet, Padding / Foam
Ceiling Tile (acoustic)
Dirt
Drywall
Landscape Debris
Mixed C&D Debris
Mixed Inerts
Roofing Materials
Scrap Metal
Stucco
Unpainted Wood & Pallets
Garbage / Trash
Other:
TOTAL
A B C Applicant Self Certified Recycling
Estimated Salvage, Estimated
Reuse or Recycle Disposal (Trash)
Estimated Total Haul (check) Facility or
Debris Quantity Dis osal Destination t----===----+-__. ___ ..;.;;;;,;;;~;;.....,a
0.00
0.00
0.00 □
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00,42_
0.00
0.00
0.00
0,00
0.00
0.00 : 0.00 0.00
To estimate Recycling Rate: (Total A/I'otal C 0.00%
j .-A-p-pl-ica_n_t_N-am_e_:-!!5~:J?~ ... ~ ... :(----.,_{ _.......,.l Slgnature:
0
...-'11-------Date: ft/~ 'l,,f,,
For infonnation on construction and demolition waste management plans contact the City of Diamond Bar
Environmental Services at 909 .839.7015 or via email to greendb@diarnondbarca.gov
-1 -09/28/17