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{a � : WORKSHEET FOR POOL COMBINATION PERMIT APPLICATION
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CITY OF NEWPORT BEACH
BUILDING DIVISION (- .1 A, ra �\ /A 2
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1. PROJECT ADDRESS (NOT MAILING ADDRESS)
601 G Ic's N.`bj CI q2,663
LEGAL DESCRIPTION
LOT
BLOCK
TRACT
2. DESCRIPTION OF WORK lX C M i a b f-67
ESTIMATED $ VALUATION i t 000
SWIMMING POOL P' SPA POOL FENCING ❑ DRAINAGE ❑
Check Appropriate box for Applicant
3. OWNER'S NAME LAST FIRST
601 L; cd R3 li ssdc i d�,
ADDRESS
OWNER'S E-MAIL ADDRESS
CITY STATE ZIP
PHONE NO.
Ne 4 ))DeA(h 064 g2,-6 3
4. LAST FIRST
LICENSE N0.
CPY" C�
ADDRESS
ENGINEER'S E-MAIL ADDRESS
9 092 b a f ,^ Avk. t67
CITY STATE ZIP
PHONE NO.
I mhivl Vcl )e 9z ,
9 `l9
5. CONTRACTOR'S NAME
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BUSINESS LICENSE
STATE LICENSE
IDb.S
�No?t/,,:,--'06cC6I'ass
2. Z �-
anm 1. f d(3)
3
ADDRESS
CONTRACTOR'S E-MAIL ADDRESS
q n�ax
CITY STATE ZIP
PHONE NO.
C f') e5a 9�2 6ZG
9�I q 9y5 �j'q'c
:E USE ONLY
PERMIT NO. SGS/�0(
PLAN CHECK NO. Z, --7b,- Z -0I
POOL P/C FEE $
DRAINAGE P/C FEE $
Forms\Pool spa appl (rev3-04).xls