HomeMy WebLinkAboutS2019-0160 - Permit Application�Z0�G -ZZ
WORKSHEET FOR POOL COMBINATION PERMIT APPLICATION
CITY OF NEWPORT BEACH
BUILDING DIVISION
PLEASE PRINT OR TYPE
1. PROJECT ADDRESS (NOT MAILING ADDRESS)
j 7 L�b1 4 St-�
LEGAL DESCRIPTION
LOT BLOCK TRACT
2. DESCRIPTION OF WORK ('��1 ` r"I 7' Uv I V VFL i ka
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ESTIMATE $' VALUATIO LI a03
SW I1diRh*+G4 A94- ❑ SPA POOL ff-M Hdf; -0 RA
Check Aoorooriate box for Annlicant
3. OWNER'S N ME LAST FIRST
�liN
ADDRESSOWNER'S
9-7 bJD4
E-MAIL ADDRESS
,sem
CITY p STATE N / ZIP
9_2-&6,3&�6,3
PHONE NO.
9g'),Z&l �7Z
4. ENGINEE'S NAME LAST FIRST
LICENpSEE NO.
C� (�
'r� 1`- 'cOJ
7
AADDRESSENGINEER'S
E-MAIL ADDRESS
�V � S�
CITY TATE ZIP
PHONE NO.
1-740b�?o:)
5. CONTRACTOR'S� \)
BUSINESS LICENSE
STATE LICENS
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(-
l.ADDRESS / C {'
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CONTRACTOR'S E-MAIL ADDRESS
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l/ ` , l_�Zi�J/�
l
CITY STATE ZIP
C�4 cc �l2IL
PHONE NO.
i 2
OFFICE USE ONLY
PERMIT N0.
PLAN CHECK NO. !� ZC l 1
POOL P/C FEE $
DRAINAGE P/C FEE $
Forms\Pool spa appl (rev3-04).xls —D ?
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