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WORKSHEET FOR POOL COMBINATION PERMIT APPLICATION
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CITY OF NEWPORT BEACH
BUILDING DIVISION
PLEASE PRINT OR TYPE
1. PROJECT ADDRESS (NOT MAILING ADDRESS)
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LEGAL DESCRIPTION
LOT 54I BLOCK TRACT 306z
2. DESCRIPTION OF WORK
JSp Poel and
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ef<<. Stub
ESTIMATED $ VALUATION
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SWIMMING POOL
SPA (�
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POOL FENCING ❑ V
W/' DRAINAGE (�
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
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LICENSE NO.
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ADDRESS ENGINEER'S E-MAIL ADDRESS
CITY STATE ZIP
PHONE NO.
5. CONTRACTOR'S NAME
BUSINESS LICENSE
STATE LICENSE
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No. s
ADDRESS
CONTRACTOR'S E-MAIL ADDRESS
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CITY STATE ZIP
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PHONE NO.
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OFFICE USE ONLY 61uj I-0 r Q SS
PERMIT NO.
PLAN CHECK NO. 1Q>7-12--oaww
POOL P/C FEE $
DRAINAGE P/C FEE $
Forms\Pool spa appl (rev3-04).xis