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WORKSHEET FOR POOL COMBINATION PERMIT APPLICATION
CITY OF NEWPORT BEACH
BUILDING DIVISION 1
PLEASE PRINT OR TYPE v
1. PROJECT ADDRESS (NOT MAILING ADDRESS)
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ILEGAL DESCRIPTION �jll V U y I
LOT BLOCK CT
2. DESCRIPTION OF WORK u Y
ESTIMATED $ VALUATION ZOO
SWIMMING POOL ❑�/LSPA 9T""� -ROC1L EENCtiGl DRAINAGE
Check Annronriate box for Anolicant
3. OWNER'S NAME LAST FIRST
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ADDRESSOWNER'S
E-MAIL ADDRESS
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CITY STATE ZIP
1\hFvR;- '�-t2,(,s 7
PHONE NO.
9Vi 93 3
❑ 4. ENGIN R'S NAME LAST FIRST
LICENSE NO.
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ADDRESS
ENGINEER'S E-MAIL ADDRESS
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CITY STATE ZIP
&"2 C
PHONE NO.
1710m(aD
5. CONTRACTOR'S NAME
BUSINESS LICENSE
STATE LICENSE
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ADDRESS
CONTRACTOR'S E-MAIL ADDRESS
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CITY/ STATE ZIP
CITY
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PHONE NO.
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Z USE ONLY
PERMIT NO.
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Forms\Pool spa appl (rev3-04).xls
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