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WORKSHEET FOR POOL COMBINATION PERMIT APPLICATION
CITY OF NEWPORT BEACH SZplq W ��
BUILDING DIVISION
2. DESCRIPTION OF WORK d�-iXlS%e2 /�X/^IS/��� P L /UeGJ
/ V � ESTIMATED $VALUATION J� 1000SWIMMING POOL 1� SPA POOL FENCING DRAINAG
Check Appropriate box for Applicant
3. OWNER'S NAME sT FIRST
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ADDRESS
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OWNER'S E-MAIL ADDRESS
CITY� C TE �U6 O
PH NE NO.
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4. ENGINEER' N� LST FIRST
LICENSE NO.
ADDRESS
ENGINEER'S E-MAIL ADDRESS
CITY STATE ZIP
PHQI41E NO.
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51. C/ONTRAC�rT/O S/�/A�ME
BUSINESS LICENSE
STATE LICENSE c�
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No. Class✓
ADDRESS
CONTRACTOR'S E-MAIL ADDRESS
CITY STATE ZIP
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PHONE NO.
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PERMIT NO. X ?���1 d
PLAN CHECK NO.
POOL P/C FEE $ '
DRAINAGE P/C FEE $
Forms\Pool spa appl (rev3-04).xls