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Please print 3 copies
Associated Building Permit #
Worksheet for Fire Permit Application
City of Newport Beach - Building Division �i 01 R• OHq 3
ire Sprinkler F_ Fire Alarm r Fire Misc
1. Project Address (Not mailing address) Floor Suite No
l y Z-- 142 /4 40r-- - F_
Tenant NameL) #Units
2. Description of Work
Use
Owner's E-mail Address
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State �—
Extg Sq Ft F New/Added Sq Ft Total Sq Ft
Valuation $ �,'Z C,
r New r Add F_ Alter r Demo
#Stories
Check Appropriate Box for Applicant/Notification
F_ 3. Owner's Name Last—
First;
Owner's Address
Owner's E-mail Address
City �—
State �—
Zip [_ TelephoneF_
F_ 4. Arch itect/Designer's Name
Last
First Lic. No.
Architect/Designer's Address
Architect/Designer's E-mail Address
City
State �—
Zip [_ Telephone F_
F_ 5. Engineer's Name Last
First F Lic. No.l
Engineer's Address
Engineer's E-mail Address
City I
State F_
Zip I Telephones
6. Contractor's Name Last' First f ��,�.� Lic. No. ���/Class,
1�
Contractor's Address
Contractor's E-mail Address
City %l �l6 ���°�
State
Zip / Telephone /� / _7���`
OFFICE USE ONLY
, —
PERMIT NO. v
TYPE OF CONSTRUCTION
�^
PLAN CHECK NO.
OCCUPANCY- GROUP
V
u®� PLAN CHECK FEE $
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