HomeMy WebLinkAboutS2021-0004 - Permit Application (2)S 26) 661)I° 2-5`f'I
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WORKSHEET FOR POOL COMBINATION PERMIT APPLICA 0
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CITY OF NEWPORT BEA��//�
BUILDING DIVISION
PLEASE PRINT OR TYPE QA ° y
1. PROJECT ADDRESS (NOT MAILING ADDRESS) ,
LEGAL
BLOCK
2. DESCRIPTION OF WORK
ESTIMATED$VALUATION,416" 664
SWIMMING POOL ❑ SPA I/ POOL FENCING ❑ DRAINAGE ❑
Check ADDrooriate box for Aoolirant
3. OWNER'S NAME LAST FIRST
ADDRESS
OWNER'S E-MAIL ADDRESS
CITY STATE ZIP
PHONE NO.
4. ENGINEER'S NAME LAST FIRST
LICE NS/E�NO.
,
ADDRESS
ENGINEER'S E-MAIL ADDRESS
CITY STATE ZIP
PHONE NO.
® 5. CONTRACTOR'S NAME
BUSINESS LICENSE
511De4
STATE LICENSE
lNo.t,'ll'10 Class _S
ADDRESS
CONTRACTOR'S E-MAIL ADDRESS
CITY STATE ZIP
^, n �: 2 0
PHONE NO.
7.'N 3r
OFFICE USE ONLY
PERMIT NO.
PLAN CHECK NO. y
POOL P/C FEE $ `�`F
DRAINAGE P/C FEE $ /C ✓
Forms\Pool spa appl (rev3-04).xls 20 ! C.I.—+ �' ),, 1 C