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°g� "°°" WORKSHEET FOR POOL COMBINATION PERMIT APPLICATION
"°+u.••+�i`.. CITY OF NEWPORT BEACH
BUILDING DIVISION
PLEASE PRINT OR TYPE
1. PROJECT ADDRESS (NOT MAILING ADDRESS)
LEGAL DESCRIPTION
LOT BLOCK TRACT
2. DESCRIPTION OF WORK
L
ESTIMATED $VALUATION �, Do -0
SWIMMING POOL SPA � ❑ DR°I-° °G�- n
Cher -k Annronriate hox for Annlicant
3. OWNER'S NAME LAST FIRST
14gr��
ADDR SS
VVN �y ' y"
OWNER'S E-MAIL ADDRESS
CITY STATE ZIP
PHONE NO.
9t[9 e�3 7
4. ENGINEER'S NAME LAST FIRST
p
LICEN E NO.
?
C��Z' �2
ADDRESS
ENGINEER'S E-MAIL ADDRESS
CITYTATE ZIP
ti-- o � 2
PHONE NO.
/1(10061
P�5. CONTRACT R'S NAME (� /� /� �%
Ubvjr(_fJ�' �
BUSINE S LICENSE
STATE LICENSE
(5�
No. 2 ZS/Class
ADDRESS
CONTRACTOR'S E-MAIL ADDRESS
bA5 5T
)OVA
CHONE
N-bifoe--%I I eoc ct_E y 0660 ZIP
NO.
y
P9c/q L/S�� 7W
:E USE ONLY
PERMIT NO.
PLAN CHECK NO.
POOL P/C FEE $
DRAINAGE P/C FEE $
Fortes\Pool spa appl (rev3-04).xis