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WORKSHEET FOR POOL COMBINATION PERMIT APPLICATION
CITY OF NEWPORT BEACH
BUILDING DIVISION
PLEASE PRINT OR TYPE
1. PROJECT ADDRESS (NOT MAILING ADDRESS) /
-% /�4141
LEGAL DESCRIPTION
LOT BLOCK TRACT
2. DESCRIPTION OF
SWIMMING POOL ❑ SPA ❑
Check Appropriate box for Applicant
_ ESTIMATED $ VALUATION IS coo
POOL FENCING ❑ DRAINAGE ❑
3.
OWNER'S NAME
9
/9
LAST
FIRST
il i/S
F r
-f�L
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.
CQNTRACT� NAME
J
BUSINESS LICENSE
STATE LICENSE
L^ y
%�
No. Class
ADDRESS
CONTRACTOR'S E-MAIL ADDRESS
CITY
STATE
ZIP
PHONE NO.
�A
2
G
,
:E USE ONLY
PERMIT NO.
PLAN CHECK NO.
POOL P/C FEE $
DRAINAGE P/C FEE $
2�c-IA oaf
Forms\Pool spa appi (rev3-04).xls