HomeMy WebLinkAboutX2022-0085 - Permit Applicationfat wniRGta,
WORKSHEET FOR POOL COMBINATION PERMIT APPLICATION
CITY UILDI G DIVISION OF NEWPORT CH n 2022'��
11-MOC rKill1 VR 1 TrC
1. PROJECT ADDRESS (NOT MAILING ADDRESS)
�$O�'j �r!OSYJ�`�i�i0 KIK •
IgxH_A
TRACT
2. DESCRIPTION OF WORK O &eVv6\\ kIOT-J
ESTIMATED $ VALUATION IS4ecO
SWIMMING POOL ❑ SPA ❑ 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.
4. ENGINEER'S NAME LAST FIRST
LICENSE NO.
ADDRESS
ENGINEER'S E-MAIL ADDRESS
CITY STATE ZIP
PHONE NO.
5. CONTRACTOR'S NAME
BUSINESS LICENSE
STATE LICENSE
No.ClassIf
ADDRESS
�JGYJ� aFEI.IGe� 4�� t b'�
CONTRACTOR'S E-MAIL ADDRESS
wr�+�• &'jvuAS w•�t�. e
CITY S/T�ATE igZIIPr
PHONE NO.
'E USE ONLY
PERMIT NO.
PLAN CHECK NO.
POOL P/C FEE $
DRAINAGE P/C FEE $
x zo z�2 - DcoQes
Forms\Pool spa appl (rev3-04).xls
N