HomeMy WebLinkAboutX2012-0796 - Permit ApplicationIN PNI M_F x2i�l—O�tl�a
R,nntFnrm^r, Worksheet for Building Combo Permit Application�,i
F Comm F_ Residential City of Newport Beach -Building Division .- �Ivd
NOTE: PLAN CHECK FEE DUE AT TIME OF SUBMITTAL ,<„o ."
Building F_Grading [-Drainage F-Elec F Mech F7Plum cuvdCut CuYdR11
Project Address (Not mailing address) Floor Suite No
3� � 00 1�2 ?MT 9wd '� � e wgor e CA
Description of Work
Use
n
# StoriesF7 # Units (if Res)[
Valuation $
Material/Labor
New/Add SF Remodel SF�— Garage/New/Add e/New/Add—',
OWNER'S NAME Last �( — First
Owner's Address Owner's E-mail Address
City F66Yi RQ,Sa State I i Zip Morn Telephone q
APPLICANT'S NAME Last _Yv��G First J1v C1 - - -
Applicant's Address ,r Applicant's E-mail Address
Y
City _-..--. _--.._-----._--_-- State �� Zip I Telephone���
ARCHITECT/DESIGNER'S NAME Last First Lic. No.
Architect/Designer's Address Architect/Designer's E-mail Address
City —_ State Zip j Telephone[7�,
ENGINEER'S NAME Last First j Lic. No.
Engineer's Address Engineer's E-mail Address
City —, _ State �_ Zip F Telephoned
CONTRACTOR'S NAME/CO NY �5"G u�2 �Gz' _/J Lic. No. F , Class
Contractor's Address - Contractor's E-mail Address,/
/
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City �pJ�. f6'/e.d/d- State �4-_-- Zip--/1- z 7... !. Telephone l %`a'rY`o�S.`"
ENERGY P/C FEE $ FIRE P/C FEE $ PERMIT NO. h� 1 2� "Q 91!
GRADING P/C FEE $ PLANNING P/C FEE $ PLAN CHECK NO. LU.-
ELEC/PLUM/MECH P/C FEE $ PLAN CHECK FEE $
DEVELOPMENT # TOTAL FEES PAID $