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WORKSHEET FOR POOL COMBINATION PERMIT APPLICATION
CITY OF NEWPORT BEACH
BUILDING DIVISION
i (NOT MAILING ADDRESS)
LEGAL DESCRIPTION
LOT BLOCK TRACT
2. DESCRIPTION OF WORK
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SWIMMING POOL
ESTIMATED $ VALUATION zt% 1$`�^ coo
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SPA POOL FENCING ❑ DRAINAGE ❑
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3. OWNER'S NAME LAST FIRST
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ADDRESSOWNER'S
E-MAIL ADDRESS
26 Vkm-ezlaf
CITY STATE ZIP
PHONE NO.
Al& erl 60as¢ ell 904g7
4. ENGINEER'S NAME LAST FIRST
LICENSE NO.
ADDRESS
ENGINEER'S E-MAIL ADDRESS
CITY STATE ZIP
PHONE NO.
5. CONTRACTOR'S NAME
BUSINESS LICENSE
STATE LICENSE c2j
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ADDRESS
CONTRACTOR'S E-MAIL ADDRESS
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727 W (l��¢fUH -4v-o-
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CITY STATE ZIP
PHONE NO.
CL4T9 C14- `%28"67
16710109-693-7
:E USE ONLY
PERMIT NO.
PLAN CHECK NO.
POOL P/C FEE $
DRAINAGE P/C FEE $
Forms\Pool spa appl (rev3-04).xls
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