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PLEASE PR
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WORKSHEET FOR POOL COMBINATION PERMIT APPLICATION
CITY OF NEWPORT BEACH
BUILDING DIVISION
NOT MAI4ING ADDRESS)
LEGAL DESCRIPTION
LOT BLOCK TRACT
2, DESCRIPTION OF WORK SPA—
S C ESTIMATED $ VALUATION / Z epo d
X �
SPA L� PRGnL-�� �
Check Appropriate box for Applicant
Ei 3. OWNER'S NAME
LAST
FIRST
'61 lit,
ADDRESS
Z1
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OWNER'S E-MAIL ADDRESS
CITY
60ro4-- a/
STATE
ZIP
,76 2 5-
PHONE NO.
W9 2�1 //7-3
4. ENGINEER'S NAME
LAST
FIRST
LICENSE NO. r
oS
ADDRESS
p1
ENGINEER'S E-MAIL ADDRESS
V5 //.-J
CITY
STATE
ZIP
PHONE NO. /
5. CONTRACTOR'S NAME
BUSINESS LICENSE
STATELICENSE
No. ��/�7� Class
ADDRESS
ate(�,
y�
V e-1,
CONTRACTOR'S E-MAIL ADDRESS ��•�
CITY
STATE
�} ZIP
PH(OONNyE NO.
'E USE ONLY
PERMIT NO.
PLAN CHECK NO.
POOL P/C FEE $
DRAINAGE P/C FEE $
Farms\Pool spa appl (rev3-04).xls
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