HomeMy WebLinkAboutS2021-0259 - Permit ApplicationFp4 �YµPnR g� WORKSHEET FOR POOL COMBINATION PERMIT APPLICATION
ua CITY OF NEWPORT BEACH
BUILDING DIVISION
PLEASE PRINT OR TYPE
1. PROJECT ADDRESS (NOT MAILING ADDRESS)
107 V l 4 LA
LEGAL DESCRIPTION
LOT BLOCK TRACT
2. DESCRIPTION OF WORK S t'Q 7 X- 17i
ESTIMATED $ VALUATION. 4nLI<
SWIMMING POOL ❑ SPA J POOL FENCING ❑ DRAINAGE ❑
Check Appropriate box for Aonlicant
3. 0 NER'S NAME LAST FIRST
r
ADDRESS
OWNER'S E-MAIL ADDRESS
l0 i IG
CITY STATE ZIP
N0vJerr CA . owa(v
PHONE NO.
4. ENGINEER'S NAME LAST FIRST
LICENSE NO.
hIi
C 7&50
ADDRESS
ENGINEER'S E-MAILA RESS
T
CITY STATE ZIP
AC [ Akm CA zoo -�
PHONE NO.
T4.(030 • (a �
5. CONTRACTOR'S NAME
BUSINESS LICENSE STATE LICENSE
C•S
C� p
/
�" r-7 a s
CONTRACTOR'S E-MAIL ADDRESS
gCkpdeve 0� po+le.t-c{@5maLL 2,
GcrM
ADDRESS
L 5 Ca fe U (SUS c�ooD� �Yr—
CITY STATE ZIP
W I rt N2 CAc(o/vo3
IPHONE NO. y�
5Coz- Sto SIM
:E USE ONLY
PERMIT NO.
PLAN CHECK NO. Z,-7 O
POOL P/C FEE $
DRAINAGE P/C FEE $
horms\Pool spa appl (rev3-04).xls ) ^ o „ C 0 5 / ,