HomeMy WebLinkAboutPV2021-160 - Permit Application (2)( ;_Pont Form Worksheet for Combo Building & Solar Permit �A/pplication VAOIR
F- Comm'I fP Residential City of Newport Beach - Building Division y U2i'(NOTE: PLAN CHECK FEES DUE AT TIME OF $UBMIT�L
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Project Address (Not mailing address) f- Flood fT Fire F_ Liq F- Landslide FN/A Floor Suite No
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Description of Work
Use Const Type
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Valuation $
.Material/Labor
OWNER'S NAME Last
/TA 4M First
Owner's Address
C Owner's E-mail Address
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City �c7:eob=at(%e
State. Zi P � Telephoner—
APPLICANT'S NAME Last 9.
Im ��,2.�v. .First
Applicant's Address
Applicant's E-mail Address
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State Zip Telephone ;%'r (r 21 2717 ~
ARCHITECT/DESIGNER'S NAME
Last First
Lic. No. r--
Architect/Designer's Address
Architect/Designer's E-mail Address
City
State F_ Zip -- Telephone�
ENGINEER'S NAME. Last
First Lic: No.r—"--
Engineer's Address
Engineer's E-mail Address
City
State �® Zip-- Telephone—
CONTRACTOR'S NAME/COMPANY
Lic. No. F—ClassF
Contractor's Address
Contractor's E-mail Address
City
State r--- Zip F— Telephone
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SETBACKS REAR
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SETBACKS FRONT PERMIT NO. \/j<) t 7 /l - J
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