HomeMy WebLinkAboutR2020-0552 - Permit Application_ 1;,GF.IVI
City of Newport Beach
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COMMUNITY DEVELOPMENT DEPARTMENT DEVELO '
BUILDING DIVISION i5( 0 6
4�, 100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-89 a
RBR#�" Owww.newportbeach6a.gov 1 (949) 644-3200
CITY
Application for Report of Residential Building Records
Aoolication Feet - $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: Address; '� ('�„� City; Newport Beach State: oZip:l�l/1
PropertyOwner: __ _�� __U-vI !1 ,n A .�_ _.______ Zip Code: �7
Owner Address: C]E C �1—I— e—Y�.L�1/ City: C /,, Pike I ry T-1
State: CA _I J`Zip�Ccodde: � Home Phone: (S[IZ— l IO '- _iS / 2
Owner's Authorized Agent: G t Work Phone:—�
Agent Address: K16_ mi . — 3v —` -`6t ------
State: Zip Code: Agent Email Address:
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Escrow Company: Escrow#:
Escrow Address: 4A2J1 Comity
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State: I—i'1—F771 Zip Code: - Escrow Phone:
Email Report to:
For Inspection call (Name): Direct Phone:
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED SELOWI
I authorize inspections and re -inspections of the property listed above. I understand that if Building or Zoning
violations a re discovered I will be responsible to correct said violations.
Owner/Agent's signature to authorize inspection:
OR
Owner/Agent's signature to decline inspection:
Date:
Date: 177MU77
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
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