HomeMy WebLinkAboutX2021-3179 - Permit ApplicationWORKSHEET FOR POOL COMBINATION PERMIT APPLICATION
CITY OF NEWPORT BEACH
BUILDING DIVISION
PLEASE PRINT OR TYPE
1. PROJECT ADDRESS (NOT MAILING ADDRESS)
J"0 14G
LEGAL DESCRIPTI N /
LOT BLOCK (0 IA � TRACT
2. DESCRIPTION OF WORK %2G' " T% 1 /� ���
brr%hl lc� ���� ��t%�C�''� �%�r/��e ESTIMATED $ VALUATION
SWIMMING POOL SPA �-� POOL FENCING ❑
Check ADDromiate box for Annlicanif
CCU ban,)
4
F%�,. tIF� Eli
DRAINAGE ❑
3. OWNER'S NAME
LAST
FIRST
ADDRESS
OWNER'S E-MAIL ADDRESS
CITY
/L'IGUv �W7
STATE
LI/d&,F
ZIP PHONE NO.
F/�) 1
rl 4. ENG NEER'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
/!/i//�� �J
�/U�
No. �1 t� Class `J
ADDRESS
1�21j' (?I) UV e42
CONTRACTOR'S E-MAIL ADDRESS
�«r -0
e2n
CITY
11P#1
STATE
ZIP
PHONE NO.
6
:E USE ONLY
PERMIT NO,
PLAN CHECK NO.
POOL P/C FEE $
DRAINAGE P/C FEE $
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Forms\Pool spa appl (rev3-04).xls