HomeMy WebLinkAboutS2024-0078 - Permit Application" k WORKSHEET FOR POOL COMBINATION PERMIT APPLICATION
CITY OF NEWPORT BEACH
BUILDING DIVISION
PLEASE PRINT OR TYPE
1. PROJECT ADDRESS (NOT MAILING ADDRESS)
3 N M
LEGAL ESCRIPTION N y79.d)97.0
LOT BLOCK TRACT
2. DESCRIPTION OF WORK
��2w
ESTIMATED $ VALUATION
SWIMMING POOL SPA `k. POOL FENCING ❑ DRAINAGE ❑
Check Appropriate box for Applicant
® 3. OWNER'S NAME
LAST
FIRST
PI L6—& -
11► A-rJ a
ADDRESS
OWNER'S E-MAIL ADDRESS
-4� 2 3 oa-ot4 A6-M r-)
CITY
STATE
ZIP
PHONE NO,
cmQoNA t>eZ
rt A-
9
® 4. ENGINEER'S NAME
LAST
FIRST
LICENSE NO.
perc E7&"la�
06
G744S
ADDRESS����j_J
ENGINEER'S/E-MAIL ADDRESS
y..Oa A
W I d. 1
+041 \ Oo'CAM • C0%y
CITY
STATE
ZIP
PHONE NO.
�A%l► tfE
Gd
QZ1507
I/`f (P30 pp/
S. CONTRACTOR'S NAME
BUSINESS LICENSE STATE LICENSE
TOOLS/
G
I3I C004Zjs2 IN.6123dl�`�lass
CONTR TOR'S E-MA,I AADDREESS
�.T*-r4 J �i1dt rlc.69'*Q;��CO
ADDRESS
�7 �``
Zf E L�T��
CO'CA
CITY
STATE
ZIP
PH90NEf-400Z&
,A tik5
cam-
Won
R
OFFICE USE ONLY
PERMIT NO.
PLAN CHECK NO
POOL P/C FEE $
DRAINAGE P/C FEE S
FormslPool soa aDDI (rev3-041.xls