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WORKSHEET FOR POOL COMBINATION PERMIT APPLICATION
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BUILDING DIVISION
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1. PROJECT ADDRESS (NOT MAILING ADDRESS)
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LEGAL DESCRIPTION
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11 2. DESCRIPTION OF WORK I Uv l„ / kGAI n (`V\
SWIMMING POOL SPA
Check Annrooriate box for Onnlirant
_ ESTIMATED $ VALUATION
POOL FENCING ❑
DRAINAGE I
❑ 3. OWNER'S NAME LAST FIRST
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OWNER'S E-MAIL ADDRESS
CITY �/1 STATED ZIP
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PHONE NO. �7
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❑ 4. ENGINEER'S N ME LAST FIRST
LICENSE NO.
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ADDRESS
ENGINEER'S E-MAIL ADDRESS
CITY STATE ZIP
PHONE N0.
5. CONTRACTORS NAME
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BUSINESS LICENSE
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STATE LICENSE
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CONTRACTOR'S E-MAIL ADDRESS
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CITY STATE ZIP
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PHONE NO.
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:E USE ONLY
PERMIT NO.
PLAN CHECK NO.
POOL P/C FEE $
DRAINAGE P/C FEE $
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