HomeMy WebLinkAboutS2021-0136 - Permit Application52,021 f I02L�] .
WORKSHEET FOR POOL COMBINATION PERMIT APPLICATION I f
o" M
CITY OF NEWPORT BEACH
BUILDING DIVISION
PLEASE PRINT OR TYPE
I 1. PROJECT ADDRESS (NOT MAILING ADDRESS)
ITV2 A'cper wex4LPveove
LOT BLOCK TRACTy� �� I/ Z-
2. DESCRIPTION OF WORK A' e w V 6 ! X A �/As.d e/ a�®®o ✓�'
i�et6YJV17 ?�t> ESTIMATED $ VALUATION ®Ue ®u8
SWIMMING POOL ❑ SPA ❑ POOL FENCING ❑ DRAINAGE ❑
Check Appropriate box for Applicant
3. OWNER'S NAME LAT FIRST
X v g� ea® Zm Cm o 1j
ADDRESS
OWNER'S E-MAIL ADDRESS
/FV2 A&,,-/
CITY STATE ZIP
PHONE O.
�e�p a�� '�, eo Cd_ 9� ®
(5ZI) V4, - Y5®9
4. ENGINEER'S NAME LAST FIRST
LICENSE NO.
2
,L✓ r aEwJ3,�? C 14 C>�t„�(Jrra eAlC Je
"7 LID b i
,
ADDRESS
ENGINEER'S E-MAIL ADDRESS
I 2 P/ A/. 7' TI ti Xv'
A r'x/oo;7ve.b 0�1,d o'oi�a�. U
CITY STATE ZIIPy
PHONE NO..
7
A l✓At/ e I `-&,j c—,dr 9P4 !
(®v /7 x °/,C;+ %iii
5. CONTRACTOR'S NAME
BUSINESS LICENSE
I STATE LICENSE
�C.4 r✓.4 41�d® L5,3
?3S �s
Class
ADDRESS
!-? d . 61) X i
CONTRACTOR'S E-MAIL ADDRESS
Ay m CP Sr 4 1,v.4
CITY STATE ZIP
j-4iv74 A1s3 cA _ 9 z7 cf9
PHONE NO.
OFFICE USE ONLY� � � E � _ Ust
PERMIT NO. rzt-?,Z-( _U k ?),7>
PLAN CHECK NO.
POOL P/C FEE $
DRAINAGE P/C FEE $
mmi
Forms\Pool spa appl (rev3-04).xis
\r01� b�� �i8a.Z-5