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WORKSHEET FOR POOL COMBINATION PERMIT APPLICATION
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CITY OF NEWPORT BEACH
BUILDING DIVISION
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1. PROJECT ADDRESS (NOT MAILING ADDRESS)
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2. DESCRIPTION OF WORK \v fvj �-:>evor
SWIMMING POOL ❑ SPA
Check Appropriate box for Aonlicant
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ESTIMATED $ VALUATION 3 O I 0 o D /
POOL FENCING ❑ DRAINAGE [�
3. OWNER'S NAME LAST FIRST
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ADDRESS -
OWNER'S E-MAIL ADDRESS
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CITY STATE ZIP
PHONE NO.
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4. ENGINEER'S NAME LAST FIRST
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LICENSE NO.
9-uk003
ADDRESS
ENGINEER'S E-MAIL ADDRESS
X70
CITY STATE ZIP
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PHONE NO.
6_50--6k 00
5. CONTRACTORS NAME
BUSINESS LICENSE
STATELICENSE
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ADDRESS
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CONTRACTOR'S E-MAIL ADDRESS
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CITY 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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