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PLEASE PRINT OR TYPE
LOT
WORKSHEET FOR POOL COMBINATION PERMIT APPLICATION
CITY OF NEWPORT BEACH
BUILDING DIVISION
(NOT MAILING ADDRESS)
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2. DESCRIPTION OF WORK
BLOCK
TRACT
i
Ids ESTIMATED $ VALUATION
SPA DRAINAGE ❑
Check ADDrooriate box for ADDlicant
3. OWNER'S NAME LAST FIRST
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ADDRESS
OWNER'S E-MAIL ADDRESS
7iz ' II7o Scue
CITY STATE ZIP
PHONE NO.
PU,��- c � � 2 &G-�
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4. ENGINEER'S LAST FIRST
LICENSE NO.
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ADDRESS
ENGINEER'S E-MAIL ADDRESS
2 3 C)R-C� 2.5v
CITY STATE ZIP
PHONE NO.
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AG-115zg
5. CO CTOR'S NAME
BUSINESS LICENSE
STATE LICENSE 7
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No. �S/
ADDRESS
CONTRACTOR'S E-MAIL ADDRESS
C,,ITYcc STATE ZIP
PHONE NO.
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:E 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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