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Associated Building Permit #
Worksheet for Fire Permit Application
City of Newport Beach - Building Division
)i' Fire Sprinkler [7 Fire Alarm r Fire Misc
1. Project Address (Not mailing address) Floor Suite No
22 21 1 to T (+ s 7 4, -z- i )-i c vi D s
Tenant Name # Units---
- - --.. - _......................:
2. Description of Work
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Use
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Extg Sq Ft `Z tZ Gl(r New/Added Sq Ft 2 `-). Total Sq FtI
Valuation $ 'j �1.�7t;7
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# Stories I z
F_ New r Add r— Alter F" Demo
Check Appropriate Box for Applicant/Notification
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f 3. Owner's Name
Last r 7p.e First J
Owner's Address
Owner's E-mail Address
City
'.. State Zip r__ Telephoned -I,
F.-4. Architect/Designer's
Name Last First �n Lic. No. F -
Architect/Designer's Address
Architect/Designees E-mail Address
City �
State I-"�__---_ Zip f— Telephoned
F_ 5. Engineer's Name
Last—` First l ---_' LIc.No.�
Engineer's Address
Engineer's E-mail Address
City
State F Zip 1 Telephoner---�-.---.---,
(a!6. Contractor's Name
Last �� L,f liy(t First >?9/-5 �-e I Lic. No. 7" Gi3 Class C/c
Contractor's Address
Contractor's E-mail Address
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City 1 6 )Ot j'20 (3CAC(1 State F iK- } Zip C/ p'27..b,, Telephone �(0 �71 % �j lPrb
OFFICE USE ONLY
[J� �yry�\ PERMIT NO. ZcSli3 - Di C?LI
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TYPE OF CONSTRUCTION 1 ' PLAN CHECK NO.
OCCUPANCY - GROUP
PLAN CHECK FEE $
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