HomeMy WebLinkAboutX2012-0541 - Permit ApplicationPrint Form
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Worksheet for Building Combo Permit Appli Lion 00M
City of Newport Beach - Building DivisionNOTE: PLAN CHECK FEE DUE AT TIME OF SUBMITTAL
Building r Grading (-Drainage 7Elec F_Mech
F_ Plum Cu Yd Cut Cu Yd Fill F
Project Address (Not mailing address)
Floor Suite No
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Description of Work
Use
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# StoriesF # Units (if Res)
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Valuan$
MtriatioU eLaborl//y ►�U
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New/Add SF r,00 4,4,�1 Remodel SF[ Garage/New/Add s
OWNER'S NAME Last
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First
Owner's Address
Owner's E-mail Address
City Q r� G& t r l State I 1
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Zip F_ Telephonejqqq)_,CX c� ((,P�.
APPLICANT'S NAME Last 1 G) 1
Firstl.
Applicant's Address
Applicant's E-mail Address
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City�.State
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Zip ']% "'. Telephone q
F/''�Firsstt
ARCHITECT/DESIGNER'S NAME Last (% ,
w 'LV- \ - _ Q Lic. No.
Architect/Designer's Address
Architect/Designer's E-mail Address
City '.. State F
Zip Telephoned
ENGINEER'S NAME Last �/ ��/ I
First Lic. No.�
TEma:Addrddress
Engineer's AA
Engineer'sess
City -- yL/_W)e �- -_ -.. _ __. State Fa�
Zip -D`t� Telephone 0q f _1,1q (v
CONTRACTOR'S NAME/COMPANY
Lic. No. F-- Class
Contractor's Address
Contractor's E-mail Address
City State F____
Zip I TelephoneF
ENERGY P/C FEE $ FIRE P/C FEE $
PERMIT NO.
GRADING P/C FEE $ PLANNING P/C FEE $
_ PLAN CHECK NO
ELEC/PLUM/MECH P/C FEE $
PLAN CHECK FEE $
DEVELOPMENT #
TOTAL FEES PAID $
(2- \j 3 - / z. -Z-0) L