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Please print 3 copies
Associated Building Permit #
Worksheet for Fire Permit Application
City of Newport Beach - Building Division
1. Project Address (Not mailing address)
04 VIA PALERMO
Tenant Name
2. Description of Work
iX Fire Sprinkler (- Fire Alarm r Fire Misc
INSTALLATION OF A RESIDENTIAL FIRE SPRINKLER SYSTEM 31 HEADS
Extg Sq Ft 2 New/Added Sq Ft
FX_ New r Add F_ Alter F_ Demo
L,necK Appropriate tsox for Applicant/Notification
RpE Q°pRT
U S
Floor Suite No
2 2
# Units 1
Use
Valuation $ 3,500
Total Sq Ft F——
# Stories I2
F_ 3. Owner's Name Last CEFALIA
First F—
Owner's Address
Owner's E-mail Address
City I
State I.e—
Zip F_ Telephoned!
F_ 4. Architect/Designer's Name
Last First 2 Lic. No. �—
Architect/Designer's Address
Architect/Designer's E-mail Address
City
State 2
Zip �— Telephoned
f 5. Engineer's Name Last
First Lic No.
Engineer's Address
Engineer's E-mail Address
city
State �—
Zip F— Telephone—
r 6. Contractor's Name Last CASEY
First MONTY Lic. No. 876004 Class C-16
Contractor's Address
Contractor's E-mail Address
1101 KINGSTON DRIVE
fireproofmc@gmail.com
City LA HABRA
State CA
Zip 90631 Telephone (714) 476-5370
OFFICE USE ONLY
PERMIT NO. t/ OL
TYPE OF CONSTRUCTION
X'O1 to PLAN CHECK NO.
OCCUPANCY - GROUP
-b 1g PLAN CHECK FEE $