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WORKSHEET FOR POOL COMBINATION PERMIT APPLICATION
CITY OF NEWPORT BEACH
BUILDING DIVISION 92-02%-0180
1. PROJECT ADDRESS (NOT MAILING ADDRESS)
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LOT BLOCK blyz TRACT
2. DESCRIPTION OF WORK
SWIMMING POOL [9/ SPA [�
Check Appropriate box for Applicant
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;50.4
_ ESTIMATED $ V,
POOL FENCING ❑
DRAINAGE [�
OWNER'S NAME LAST FIRST
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ADDRESS
OWNER'S E-MAIL ADDRESS
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CITY STATE ZIP
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PHONE NO.
4. ENGINEER'S NAME LAST FIRST
LICENSE NO.
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ADDRESS
ENGINEER'S E-MAIL ADDRESS
CITY STATE ZIP
PHONE NO.
5. CONTRACTOR'S NAME
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BUSINESS LICENSE
STATE LICENSE
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No. Class
ADDRESS
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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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OFFICE USE ONLY (�
PERMIT NO. \l/� ) V� P{1' tlj �' L'JLX✓G+� �C�17 ��Li� b�
PLAN CHECK NO.
POOL P/C FEE $ ✓ ��
DRAINAGE P/C FEE $
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