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Box 1768 1 Newport Beach, CA 92658-8915 www.newportbeachca.gov 1 (949) 644-3200 REQUESTFOR REFUND Send permit request to your building inspector and plan check requests to the Permit Center. (*Refunds can only be reimbursed to company or individual who made original payment.) Project Address: L� I 817 b o l .5 � Permit or Plan Check , r> C, 201 C� Type ofAmount Fee: -JZPermit❑Plan Check ❑Other Paid: Date Fee Paid: $ ^� 4 - 0 PETI`fzfTjVE "�u Name (*Must be payor +off feesj1): �iVUKTIQ�� Company Name: (/ {j(� ICJ 'JV Street Address: S✓ Fe City: tt Cit Zip Code: 7.z z7 Email: Phone: Ce Fc l D � ( .1 i � ��-`— * ATTACH PROOF OF PAYMENT TO T FO eck, credit card statement or cash receipt) L) I e e r- T sw,% fcl e States 6 Reason for Requesting a Refund: I H Y RTIFY THAT THE ABOVE STATEMENT IS TRUE. Petitioner's Signature: Title:` /I r Date: FOR STAFF USE ONLY Department Action: []Approve Refund Deny Refund Comments: Inspector Approval: Name: Q/ -S C Signatu Date: :513///2 CBO Approval: Name: 5ignat re: Date: Note: Refunds are subject to a 18% administrative charge /issuance fees are not refundable. Farms\RequestforRefund 09/14/2016