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WORKSHEET FOR POOL COMBINATION PERMIT APPLICATION
CITY OF NEWPORT BEACH
BUILDING DIVISION
I rre
ZESS (NOT MAILING ADDRESS)
BLOCK
2. DESCRIPTION OF WORK Pool ZS,,,remo ds s over t f c/ I,ec,4e
Fr, Oi ^ G ESTIMATED $ VALUATION 6R,oao.
SWIMMING POOL 4 SPA ® POOL FENCING ❑ DRAINAGE 0
P k.,4 Annrnnriain hnr fnr Annliran4
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3. OWNER'S NAME LAST FIRST
/ v1 rc,
ADDRESS
OWNER'S E-MAIL ADDRESS
4v
CITY STATE ZIP
PHONE NO.
4. ENGINEER'S NAME LAST FIRST
LICENSE NO.
ADDRESS
ENGINEER'S E-MAIL ADDRESS
CITY STATE ZIP
PHONE NO.
5. CONTRACTOR'S NAME
BUSINESS LICENSE
STATE LICENSE
VL'U �ey
OT -506233&3
No.63Z33'1 Classy
ADDRESSr
CONTRACTOR'S E-MAIL ADDRESS
(3tu
�4P✓eFro ecSTATE
ZIP
PHONE NO.
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�q kj X03 Z76-1�
:E USE ONLY
PERMIT NO.
PLAN CHECK NO.
POOL P/C FEE $
DRAINAGE P/C FEE $
Forms\Pool spa appl (rev3-04).xls