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PLEASE PRINT OR TYPE
1. PROJECT ADDRESS
Sill
Sgt DO
WORKSHEET FOR POOL COMBINATION PERMIT APPLICATION
CITY OF NEWPORT BEACH
BUILDING DIVISION
(NOT MAILING ADDRESS)
BLOCK
TRACT
49 90 yW
2. DESCRIPTION OF WORK soyd e/2G 'SPA. Al-cW oECzs
f?E7UlWV F/177N('S, 04eglA✓ LU VECZS , 4eh L/ 6 ESESTIMATED $ go -
SWIMMING
h�EF'LR3'rEI2 060C, 6' SPA � ,e677W IA/IW(P W,91.4Cn t O L F K
POOL ® SPA ® POOL FENCING ❑
Check Annronriate box for Annlicant
f CA/, 000
DRAINAGE
3. OWNER'S NAME LAST FIRST
ADDRESS
OWNER'S E-MAIL ADDRESS
S,gRAi/ CC -,W F /44 FUZZ
C ydlloo, aw
CITY STATE ZIP
PHONE NO.
lew o,er 117W 4965
9`i9-375 - 71493
4. ENGINEER'S NAME LAST FIRST
LICENSE NO.
OO.o sel C/4`E /c,/bC/
ADDRESS
ENGINEER'S E-MAIL ADDRESS
CITY STATE ZIP
PHONE NO.
y�iec/ �D 7
�/4� 6 g - 6/08
❑ 5. CONTRACTOR'S NAME
BUSINESS LICENSE
STATE LICENSE
C.. x1Oz,otW4S - Cpd/I/x /di�77l�OGS''
j`7`�
,r,5-,5,r,5-,5/� �a
OA14'I /A1i/
No. S;7//96 Class
ADDRESS
CONTRACTOR'S E-MAIL DDRESS
�•%2aatn/AS 6-
o/✓H1T>iYiP.
o�o�� {�y�T ��.o2ter8N,e�%U�.1/uE
A'Lx/Ns/h/Th'1�aDLs, Cb1vJ
CITY STATE ZIPPHONE
NO.
��6
;Y: Y9"7-
OFFICE USE ONLY
PERMIT NO.
111-AVOel:1x41.401[63
POOL P/C FEE $
DRAINAGE P/C FEE $
Forms\Pool spa appl (rev3-04).xls
/ • /- 11111
-075 Z