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�Qorksheet for Building Combo Permit A.pp6icatiQn ���°'x
City of Newport Beach - Building Division
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Projact Address INrna iing address) LL ---JJJ Fl000rrr Sulte No
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Description of Work Use
# Stories # UnE 5 (if Ras)
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Valuation $ d,
New/Acid SF�� Remodel SFC -1 Garage/New/Add �1 Material/Labor�lo�
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OWNER'S NAME Last J✓'i First
Owner's Address Owner's E -mall Address
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City State �� Zip � i � Telephone 1- �-
APPLiCAKT'S NAME Last —� First --_-71
Applicant's Address Appioant`s E-mail Address
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Zip Z{�!D Telepho/ne�",_ //��,,
ARCF@fTECTfL3ESIGNER'S NANIEi Last First L� Lia. No. G G `�li_
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/ ahitectIDesignar's Address Architect/Deslgnei's E-mail Addrese -
city � � �I" °i I State G7'K i Zip _ �2�'(? �6 I TelephonerC���-I-�=�—����
ENGINEER'S NAME Last —� First Llc. No.=__=1
Engineers Address Engineer's E -mall Address
city——� State C� Zip Telephone��
�ONTRACTRR'S NRPJiElCCPMPFINY (� �I VI ` J � Li c. Nn. )oV\ V0 ClassC
Contractor's Address I Contractor's E-mail Address
1-796-7 C (iZ .vC;CI, C Sraycti: i anc�5 tun , Ccc —
City ZR�dlNC —_� State � �:,Ia Zip - Q2(pl� Telephone �j+•j�+-�61-'Z�6
_WERGY PIC FEE $ FIRE P/C FEE $ PEKtvll I NU. x (/p / 7 ng D !1-4
>RAMNG PIC FEE $ PLANNING PIC FEE $ PLAN CHECK NO. 7-30.
-LECIPLUM/MECH PIC FEE $ - PLAID CHECK FEE $
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