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PLEASE PRINT OR TYPE
WORKSHEET FOR POOL COMBINATION PERMIT APPLICATION
CITY OF NEWPORT BEACH 52018-01 1'tQ
BUILDING DIVISION
1. PROJECT ADDRESS (NOT MAILING ADDRESS)
D St.
LEGAL DESCRIPTION
LOT BLOCK TRACT
2. DICRIPTIOfV^QF V�ORK 'l.)c%lj �i' U%1 _ c 5-M
\X/ `J ij�� ESTIMATED $ VALUATION�5?5 ZYC),
SWIMMING POOL W SPA T)g POOL FENCING ❑ DRAINAGE ❑
Check Appropriate box for Aoolicant
3. OWNER'S NAME LAST FIRST
ADDRESS
OWNER'S E-MAIL ADDRESS
CITY STATE ZIP
PHONE NO.
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4. ENGINEER'S NAME LAST FIRST
LICENSE NO.
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ADDRESS
ENGINEER'S E-MAIL ADDRESS
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CITY STATE ZIP
PHONE NO.
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5. CONTRACTOR'S NAME
BUSINESS LICENSE
STATE LICENSE
No. Class
ADDRESS
CONTRACTOR'S E-MAIL ADDRESS
CITY STATE ZIP
PHONE NO.
OFFICE USE ONLY
PERMIT NO.
PLAN CHECK NO.
POOL P/C FEE $ I �✓ \ �'�
DRAINAGE P/C FEE $ t� ° ` 6� PC]
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