HomeMy WebLinkAboutS2021-0080 - Permit Application (2)WORKSHEET FOR POOL COMBINATION PERMIT APPLICATION ?'
CITY OF NEWPORT BEACHll�wi��
BUILDING DIVISION
PLEASE PRINT OR TYPE
1. PROJECT ADDRESS (NOT MAILING ADDRESS)
4�
LEGAL DESCRIPTION
LOT BLOCK TRACT "' ✓P rl
[[2.. DESCRIPTION OF WORK�y,�,J�� �c�eEa1 . /gruy {o �•r� d 16�lrl
ESTIMATED $ VALUATION / OoO
SWIMMING POOL ❑ SPA D POOL FENCING ❑ DRAINAGE ❑
Check ADDrooriate box for Annlicari4
3. OWNER'S NAME
LAST
FIRST
zhAML
ADDRESS
OWNER'S E-MAILADDRESS
14 &,ywAet
it
CITY
STATE
ZI
HONE NO.
Se". e".
44
YUS7
9f9—%z?9ag
4. ENGINEER'S NAME
LAST
FIRSTLICENSE
NO.
tit 1(w KA%
ADDRESS
W,ENGINEER'S
E-MAIL ADDRESS
� q
-E�v len
CITY
STATE
ZIP PHONE NO.
IINu+¢,
o�
2.s,r,8 `W'q•Z?�1.335'"j
5. CONTRACTOR'S NAME
BUSINESS LICENSE STATE LICENSE
ADDRESS
No. Class
CONTRACTOR'S E-MAIL ADDRESS
CITY
STATE
ZIP
PHONE NO.
OFFICE USE ONLY
PERMIT NO.
S DYD�
PLAN CHECK NO.
A1tS.ti1 q/�/
POOL P/C FEE $
DRAINAGE P/C FEE $
Forms\Pool spa appl (rev3-04).xls