HomeMy WebLinkAboutXR2022-3078 - Permit Application (3)cSG
WORKSHEET FOR POOL COMBINATION PERMIT APPLICATION
D�7 CITY OF NEWPORT. BEACH
BUILDING DIVISION
PLEASE PRINT OR TYPE
1. PROJECT ADDRESS (NOT MAILING ADDRESS) I Ibyfl S�
121 Gum �S ozsl I ? �— cas I am
LEGAL DESCRIPTION C�6 - (s71 �f >(+Zl
LOT S� BLOCK dlkn y TRACT
2. DESCRIPTION OF WORK IrAYII7C�C J VIGA l
rk �MV1 &Lt" i K lam ltAil(v6vk Lka I ESTIMATED $ VALUATION
i k�
SWIMMING POOL j SPA)] POOL FENCING ❑
Mnv Fnr Annlirnni
ivls-Io-ir
DRAINAGE 0
I] 3. OWNER'S NAME
LAsT
FIRST
rADDRESS
OWNER'S E-MAIL ADDRESS
e4 (ITY
STATE
ZIP
PHONE NO.
Bec c. \
OA
9 2 (pa o
4. ENGINEER'S NAME
LAST
FIRST
LICENSE NO.
PowK����h
S3 s4
ADDRESS
22rJ3-z
201
ENGINEER'S E-MAIL ADDRESS
pou-tv- SWt ccWf 0(20)( .Yl
CITY
Mlc5 icM Uie\o
STATE
CA
ZIP
°t2cocl I
PHONE NO.
E40t)770—Z72
5. CONTRACTOR'S NAME
BUSINESS LICENSE
STATE LICENSE �,
c�1os�
J i YYl
PP 53
No. CIaSS
ADDRESS
CONTRACTOR'S E-MAIL ADDRESS
10S3=b S\Avlo- Avv
CITY
CuS� �kLs ,
STATE
c A
ZIP
")2c Z -I
PHONE NO.
ASS z:l
OFFICE USE ONLY
PERMIT NO.
PLAN CHECK NO.
POOL PIC FEE $
DRAINAGE PIC FEE $
IKS. 00D01 554
'ons\Pool spa appl (rev3-04).xls
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