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WSHEET FOR BUILDING / FIRE PERMIT APPLICATION
} E� CITY OF NEWPORT BEACH
' BUILDING DEPARTMENT
1. PROJECT ADDRESS (NOT MAILING ADDRESS)
FLOOR
SUITE NO.
�11_
LEGAL DESCRIPTION
No. UNITS
LOT BLOCK TRACT
2. DESCRIPTION OF WORK % ` USE
# OF STORIES �-
VALUATION $ ���
NEW ❑ ADD ❑ ALTER ❑ DEMO ❑ SQ FT
bVi
Qpj (NEW/ADDED/EXTG)
OWNER'S ARS
CITY � STAT
❑ 4. ARCHITECT/DESIGNER'S NAME LAST
ARCHITECT/DESIGNER'S ADDRESS
CITY
STATE
OWNER'S E-MAIL ADDRESS
ZIP PH?EV Q.
FIRST LIC. NO.
HITECT/DESIGNER'S E-MAIL ADDRESS
PHONE NO.
❑ 5. ENGINEER'S NAME LAST FIRST STATE LIC. NO.
e",
ENGINEER'S ADDRESS ENGINEER'S E-MAIL ADDRESS
0 v /A- b�2 /0 44-1 f"l, 14 2wo
CITY a� STA ZIP PHONE NO.
® 6. CONTRACTOR' BUSINESS�-�� No %�'�Clas
CONTRACTOR'S ADDRESS CONTRA TOR'S E-MAIL ADDRESS
CITY STAT ZIP PHONE O.
Cf - °A- � �� 2-7 C0 f - 3 i6
PERMIT NO.
TYPE OF CONSTRUCTION PLAN CHECK NO.
PLAN CHECK FEE $
OCCUPANCY - GROUP PLAN CHECK ENG
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HARBOR RESOURCES DIV
'.: CITY OF NEWPORT BEACH
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WORKSHEET FOR BUILDING / FIRE PERMIT APPLICATION
?Ewr CITY OF NEWPORT BEACH
BUILDING DEPARTMENT
PI GACG DRIAIT (1R TVDF °+e,"'�•
1. PROJECT ADDRESS (NOT MAILINGADDRESS)
FLOOR
SUITE NO.
LEGAL DESCRIPTION
No. UNITS
LOT BLOCK TRACT
2. DESCRIPTION OF WORK
NEW ❑ ADD ❑ ALTER ❑ DEMO❑
Check Appropriate Box
USE
# OF STORIES
VALUATION $
SQ FT
(NEW/ADDED/EXTG)
❑ 3. OWNER'S NAME LA ^ FIRST
OWNER'S ADDRES C�
OWNER'S E-MAIL ADDRESS
CITY STAT�n� � ZIP
PHON
7
❑ 4. ARCHITECT/DESIGNER'S NAME LAST FIRST
LIC. NO.
ARCHITECT/DESIGNER'S ADDRESS
ARCHITECT/DESIGNER'S E-MAIL ADDRESS
CITY STATE ZIP
PHONE NO.
❑ 5. ENGINEER'S NAME - LAST FIRST
� � L L/� 71-1
STATE LIC. NO.
/ 1�
ENGINEER'S ADDRESS -ENGINEER'S
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E-MAIL ADDRESS
CIT ST ZIP
P NO ,
❑ 6. CONTRACTOR'S NAME
C� I
BUNESSL]IC7.
STATE LIC. _�
No. 7�� tTass-
CONTRACTOR'S ADDRESS
CONTRACTOR'S E-MA L ADDRESS
CIT STATE � P,
PHOF /
OFFICE USE ONLY
PERMIT NO.
TYPE OF CONSTRUCTION PLAN CHECK NO.
PLAN CHECK FEE $
OCCUPANCY- GROUP PLAN CHECK ENG.
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