HomeMy WebLinkAboutR2020-0412 - Permit Application (2)Prnt Form City of Newport Beach
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COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION yl -
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-8915
RBR# % 7t�'i21� O4\7� www.newportbeachca.gov 1 (949) 644-3200
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Application Fee: - $191.00 Notice: ..SRT B001
(For AIIResidential Buildings) Applications with insufficient fee payment
Reinspection Fee $129.00 or incomplete will be returned
Please type or print and complete all information
# of Units: Address: J� I lam�ic�� - City: Newport Beach State: CA Zip: Gaye(02
PropertyOwnera NYl'iha M UaYCI 0 Zip Code: I
Owner Address: City:
State: CA Zip Code: Home Phone:
Owner's Authorized Agent: �� i�bw ms Work Phone: I qt- - - Wg_/T
Agent Address: City:
State: �� Zip Code: F Agent Email Address:
Escrow Company: m uu Escrow#: b5^��IS
Escrow Address: !Ab LW (1 C- 'Y l V , #-
State: F04 Zip Code: RMW
Email Report to:
For Inspection call (Name):
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City: jww-PbA L (I
Escrow Phone: t L L4 L4 j
Direct Phone: 1 (4I A
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:
Date:
OR ���., I
Owner/Agent's signature to decline inspection: Date:1 �I2j1I
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Account # 01050504-521040 .................Make checks payable to: CITYOF NEWPORT BEACH