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PLEASE PRINT OR
WORKSHEET FOR POOL COMBINATION PERMIT APPLICATION
CITY OF NEWPORT BEACH�/Io2l _011/�I I
BUILDING DIVISION G VU`I
YKVJtI:I AUUKtbb(NOT MAILING ADDRESS)
9
LEGAL DESCRIPTION
LOT BLOCK TRACT
2. DESCRIPTION OF WORK O c � a S c ^ q
ESTIMATED $ VALUATION
SWIMMING POOL E;�� SPA POOL FENCING ❑ DRAINAGE ❑
Check Annronriate box for Annfir-ant
3. OWNER'S NAMELAST a.-
c)I 9/l Com. k
ADDRESSOWNER'S
ovtv cZ11-
E-MAIL ADDRESS
6 6
CITI STATE ZIP
PHONE NO.
4. ENGINEER'S NAME LAST FIRST
LICENSE NO.
ADDRESS
ENGINEER'S E-MAIL ADDRESS
CITY STATE ZIP
PHONE NO.
5. CONTRACTOR'S NA
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BUSINESS LICENSE
STATE l6 OLICENNSEE2D'�
No? G JCIa/z
A DRESS
23 �[,I
CONTRACTOR'S E-MAIL ADDRESS
CI STATE ZIP IPHONE
NO.
OFFICE USE ONLY
PERMIT NO.
zmjc�?."k
00041
PLAN CHECK NO.
POOL P/C FEE $
DRAINAGE P/C FEE $
Forms\Pool spa appl (rev3-04).xls