HomeMy WebLinkAboutS2021-0036 - Permit ApplicationWORKSHEET FOR POOL COMBINATION PERMIT APPLICATION
CITY OF NEWPORT BEi
BUILDING DIVISION
PLEASE PRINT OR TYPE
1. PROJECT ADDRESS (NOT MAILING ADDRESS)
1918 port Plc`c@ I New or+ Reack
LEGAL DESCRIPTION
LOT T / BLOCK TRACT 77iV 3Z
2.DESCRIPTION OtFWORK R`efietiSh alaSl�etr ;11 P, , ri.place
SAA lemYeV— om cC 1 p vwe P ESTIMATED $ VALUATION 000
SWIMMING POOL ❑ SPA POOL FENCING ❑ DRAINAGE ❑
Check Aooroorlate box for Applicant
OWNER'S NAME LAST FIRST
MolleHko f j'vtzk
ADDRESS
let? Port T-Pyr;, Place
OWNER'S E-MAIL ADDRESS
Teack.mollehkopf(EJ m4d.co
CITY STATE ZIP
Ntu.Por4 9-e&Cik CA 0/Z6W
PHONE NO.
bZ6.705, y359
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
STAVE LICENSE
No. Class
ADDRESS
CONTRACTOR'S E-MAIL ADDRESS
STATE ZIP
::17
PHONE NO.
OFFICE USE ONLY
PERMIT NO.
PLAN CHECK NO.
POOL P/C FEE $
2c -)
z
DRAINAGE P/C FEE $
Forms\Pool spa appl (rev3-04).xls