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WORKSHEET FOR POOL COMBINATION PERMIT APPLICATION
CITY OF NEWPORT BEACH
BUILDING DIVISION
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1 PROJECT ADDRESS (NOT MAILING ADDRESS)
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LEGAL DESCRIPTION
LOT BLOCK TRACT
2. DESCRIPTION OF WORK 5' \,%%b ?oot gU 49wuvgt sen"AA wwkk, USo- b�OLK
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SWIMMING POOL ❑
SPA [I POOL FENCING X DRAINAGE ❑
Check Appropriate box for Applicant
3. OWNER'S NAME
FIRST
/rLAST
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ADDRESS -
OWNER' E-MAIL ADDRESS
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CITY
STATE
ZIP
PHONE NO.
4. ENGINEER'S NAME
LAST
FIRST
LICENSE NO.
ADDRESS
—77777ENGINEER'S
E-MAIL ADDRESS
CITY
STATE
ZIP
PHONE NO.
5. CONTRACTOR'S NAME
BUSINESS LICENSE _
STATE LICENSE
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No.2T 19 53 Class C
ADDRESS jCONTRACTOR'S
E-MAIL ADDRESS
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CITY
STATE
ZIP PHONE NO.
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CE USE ONLY
PERMIT NO.
PLAN CHECK NO.
POOL P/C FEE $
DRAINAGE P/C FEE $
a0010
Forms\Pool spa app] (rev3-04).xls _ 6
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