HomeMy WebLinkAboutR2020-0440 - Permit ApplicationCity of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach,
RBR# Q www,newportbeachca.gov 1 (949) 644-3200.
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COMMUNITY
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CA92658-85151 9 2020
CITY OF
Application for Report of Residential Building Record*
'4427ORT Wa
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
#ofUnits:n Address: T] Ity: Newport Beach State: ElZip: �Z.S
Property Owner. t/ d jt1-IJ _, l.>LI tQ..2 S Zip Code:
Owner Address: Z� C%A,/'+(�, City:
State: Ii_l.
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Owner's Authorized Agent: Work Phone:
Agent Address: 1— sl i? � City:
State: IC Zip Code: I Agent Email Address: L C l V Vy..r'ICA
Escrow Company: S Escrow
Escrow Address: ' City:
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State: Zip Code: �11-Lf- ... Escrow Phone: Q4t f I --
Email Report to: �j r�' q►^��t �''}n r�' �,p'/`v��-c-�—�
For Inspection call (Name):"• Direct Phone:
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED 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 correct said violations.
Owner/Agent's signature to authorize inspection:
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Date:
rDocuSlgned by:
Owner/Agent's signature to decline inspection: I U,JIuAAAtAntaSPaS Date: 6/17/2020
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Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
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