HomeMy WebLinkAboutR2020-0296 - Permit ApplicationDocuSign Envelope ID: 6C45D895-CBF4-41A4-9638-156C714BD638
Print Form City of Newport Beach �,-
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COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION -)PMENa
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 92658-89164AR 17 2020
RBR# 1c,7D2� _ d ACL b www.newportbeachca.gov 1 (949) 644-3200
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Application Fee; - $191.00 Notice:
(For All Residential Buildings) Applications with insufficient fee payment
Reinspection Fee $129.00 or incomplete will be returned
Please type or print and complete all information
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Owner Address: P City:
State: CA Zip Code: Gd(�cli
Zip Code:
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Home Phone: 11 4. q-1 "3 - a
Owner's Authorized Agent: M � tr -De-le, J `) r Work Phone: C Ln . cl,)Cl
Agent Address: q�'j . I I rlr�l i1 . C,A(1 Ty- O`- City: C v; r1c, v
State: r`�- Zip Code: CT,A is I S! Agent Email Address: Kay 0 K, -
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Escrow Company: I C,S17 A 0LX-) S
Escrow Address:
State: Zip Code: 1 ( j (yt) I
Escrow #:I
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Escrow Phone: H14A LW(p
Email Report to: c, � j e 1�G�, (; \` f� �u rn 0 ca fl UIQ
For Inspection call (Name): / A i I f ` Direct Phone: k/ f
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CONSENT TO INSPECT (FORM MUST BE SIGNED lkDATED BELOW)
I authorize inspections and re -inspections of the property listed above. I understand that if Building or Zoning
violations are discovered I will be responsible to correctsaid violations.
Owner/Agent's signature to authorize inspection: lei ( Ar Date:
OR
.US,gn.d by-
Owner/Agent's signature to decline inspection:[�-
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by:
Hcu9u11La U1wuwu4-5Z1U4u .................Make checks payable to: CITY OF NEWPORT BEACH
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