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of WORKSHEET FOR POOL COMBINATION PERMIT APPLICATION
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BUILDING DIVISION
PLEASE PRINT OR TYPE
1. PROJECT ADDRESS (NOT MAILING ADDRESS)
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LEGAL DESCRIPTION
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2. DESCRIPTION OF WORK ,A DD -A cozzZi '3 rA IS'60 l3e> "-c P 13EA .'<f 70(f L
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SWIMMING POOL ❑ SPA)EL POOL FENCING ❑ DRAINAGE ,�I;
Check Appropriate box for Applicant
3. OWNER'S NAME LAST FIRST
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ADDRESS
OWNER'S E-MAIL ADDRESS
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CITY STATE ZIP
PHONE NO.
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4. ENGINEER'S NAME LAST FIRST
LICENSE NO.
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ADDRESS
ENGINEER'S E-MAIL ADDRESS
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CITY STATE ZIP
PHONE NO.
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5. CONTRACTOR'S NAME
BUSINESS LICENSE
STATE LICENSE
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ADDRESS I,-
CONTRACTORS E-MAIL ADDRESS
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STATE ZIP
PHONE NO.
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IFFICE USE ONLY
PERMIT NO. )OA v
CHECK NO. 2`�
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DRAINAGE P/C FEE $
Forms\Pool spa appl (rev3-04).xls