HomeMy WebLinkAboutS2021-0181 - Permit Applicationev wrn
,+ rm WORKSHEET FOR POOL COMBINATION PERMIT APPLICATION
CITY OF NEWPORT BEACH
BUILDING DIVISION
PLEASE PRINT OR TYPE — - —
1. PROJECT ADDRESS (NOT MAILING ADDRESS)
C 5 u r
LEGAL DESCRIPTION
LOT BLOCK TRACT
2. DESCRIPTION OF WORK F -o -y Z 3 S� 54, 2
ESTIMATED $ VALUATION 35`t.
SWIMMING POOL Vq- SPA ❑ POOL FENCING ❑ DRAINAGE ❑
Check Aaoroulate box for Aoolicant
3. OWNER'S NAME LAST FIRST
1- i112�
ADDRESS
OWNER'S E-MAIL ADDRESS
7Llai 71
CITY STATE ZIP
PHONE NO.
4. ENGINEER'S NAME LAST FIRST
LICENSE NO.
ADDRESS
ENGINEER'S E-MAIL ADDRESS
f7vol ,/1/ L' 4v
CITY STATE ZIP
PHONE NO.
9 ' ��Z�6 �
7(' ,G, � r'a exp
5. CONTRACTOR'S NAME
BUSINESS LICENSE
STATE LICENSE
_Svckk�
No. ass
ADDRESS
CONTRACTOR'S E-MAIL ADDRESS C .7u � C,
% [' /
7G �UC ( 5 `(cert S
�zzY,+utYteJCe1 �ctdl4r
CITY STATE ZIP
PHONE NO.
L 6 LrY C'� y2.9 -TL,
OFFICE USE ONLY
PERMIT NO.'�� •f� /�� ��j
PLAN CHECK NO.
POOL P/C FEE $
DRAINAGE P/C FEE $ l I dA 4 m l
Forms\Pool spa appl (rev3-04).xls