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Please print 3 copies
Worksheet for Building/Fire Permit Application
City of Newport Beach
Building Department (9
1. Project Address (Not mailing address)
Floor Suite No
Owner's Address
4
- F
Legal Description
Lot F_ BlockF—
Tract # Units F
2. Description of Work
Architect/Designers Address
Architect/Designers E-mail Address
Use I Moor Boat
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Engineers Address
Engineers E-mail Address
12500 Via Cabrillo Marina #200
# Stories
Tenant Name if Commercial
6. Contractor's Name Last swift Slip First F Lic. No. F797052 ClassIA
Valuation $ 1Z �110-1119
New F- Add
F- Alter f- Demo tj n44;n
I bhswiftslip@sbcglobal.net
Sci Ft (new/add/extended) F
Check Appropriate Box for Applicant/Notification Information
f— 3. Owner's Name Last
A. I/
FirstFmf A
Owner's Address
Owners E-mail Address
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C.ty State L__T_
TelephoneF�/ —
zip F_
4. ArchitecVDesigner's Name Last FirstF Lic. No.
I F
Architect/Designers Address
Architect/Designers E-mail Address
city State F_
zipj TelephoneF_
S. Engineer's Name Last Bazley
First Lic. No. 9
FT, rn IC5001
Engineers Address
Engineers E-mail Address
12500 Via Cabrillo Marina #200
City I San Pedro State FCA
zipF TelephoneF310-548-3132
6. Contractor's Name Last swift Slip First F Lic. No. F797052 ClassIA
Contractors Address
Contractors E-mail Address
12027 Placenta Ave
I bhswiftslip@sbcglobal.net
city I Costa Mesa State ICA
Zip [92627 Telephone[949-631-3121
OFFICE USE ONLY
PERMIT NO.
TYPE OF CONSTRUCTION
PLAN CHECK NO.
PLAN CHECK FEE $
OCCUPANCY- GROUP
PLAN CHECK ENG.
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