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PLEASE PRINT
1. PROJECT A
i ID
LOT
WORKSHEET FOR POOL COMBINATION PERMIT APPLICATION
CITY OF NEWPORT BEACH
BUILDING DIVISION
PE
SS (NOT MAILING ADDRESS)
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2. DESCRIPTION OF WORK
BLOCK
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SWIMMING POOL Z' SPA
Check Aooronriate box for Annlirant
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POOL FENCING ❑
Llii
S20Z1-0090
DRAINAGE ❑
3. OWNER'S NAME LAST FIRST
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ADDRESS
3ZL-( [�rte ((z
OWNER'S E-MAIL ADDRESS
CITY STATE ZIP
Ij L (iq D r.1' Ut 6 Pr ZOO
PHONE NO.
, (� CZ�-- C�7- �5,� �g
0 4. ENGINEER'S NAME LAST FIRST
LICENSE NO.
no 1 ENi (��2lin i hC.
67L
AD RESSENGINEER'S
E-MAIL ADDRESS
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CITY STATE ZIP
PHONE NO.
Ari. hr e -, CIA Z &0-7
0 5. CONTRACTOR'S NAME
BUSINESS LICENSE STATE LICENSE
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No. IOi3�6 I ClassCS3
ADDRESS
CONTRACTOR'S E-MAIL ADDRESS
,32-y3Z 4Z-
I1Ue_c
CITY STATE ZIP
PHONE NO.
crt s � c14 411Z0
OFFICE USE ONLY
PERMIT NO. Ij
PLAN CHECK NO.
POOL P/C FEE $\
DRAINAGE P/C FEE $
Forms\Pool spa appl (rev3-04).xls