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PLEASE PRINT OR TYPE
1
WORKSHEET FOR POOL COMBINATION PERMIT APPLICATION
(Dn- CACII
CITY OF NEWPORT BEACH
BUILDING DIVISION
1. PROJE = (NOT MAILING AAADDRESS'
V'
Lei
LEGAL DES RIP I ION
LOT BLOCK TRACT
2. DESCRIPTION OF
SWIMMING POOL ❑ SPA 7T
Check Appropriate box for Applicant
ESTIMATED $ VALUATION
POOL FENCING ❑ DRAINAGE ❑
3. OWNER' NAME LAST FIRST
1
ADDRESSMAI
Nur1:71\[S
ADDRESS
a6lou L�
CITY STATE ZIP
3, C Ii2
PHO E NO.
32
4. ENGINEER'S NAME LAST FIRST
LICENSE NO.
ADDRESS
ENGINEER'S E-MAIL ADDRESS
CITY STATE ZIP
PHONE NO.
TOR'S NAME
5. CON:,lvtz„ �[
BUSINESS LICENSE
BUSINESS
STATE LICENSE
No. Class
ADDRESS
CONTRACTOR'S E-MAIL ADDRESS
CITY STATE ZIP
PHONE NO.
OFFICE USE ONLY
PERMIT NO. /
PLAN CHECK NO.
POOL P/C FEE $
DRAINAGE P/C FEE $
Forms\Pool spa appl (rev3-04).xls
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