HomeMy WebLinkAboutR2020-0834 - Permit ApplicationDocuSign Envelope D. D45DF161-8598-4DCD-9F5C-6FOB84CB557 RECElVE�
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Print Form City of Newport Beach c
COMMUNITY
DEVELOP
BUILDING D VISION DEPARTMENT .41 BVELOpM�NT
100 Civic Center Drive I P.O. Box 1768 Newport Beach, CA 92658-8915 '-
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Application for Report of Residential Building Records
Application Fees: Single Family Res/Condo (lunit) - $165.00
Notice:
Duplex (2 Units) - $192.00
Application with insufficient fee payment
More than 2 units - $192.00 + 11.00 per unit over 2
or incomplete will be returned
Reinspection Fee $88.00
Please type or print and complete
all information
# of Units: Address: 22 Vernon
City: Newport Beach State: CA Zip: 92657
Property Owner: Cynthia Jane Burleson
Zip Code:
Owner Address:
City:
State: CA Zip Code:
Home Phone:
Owner's Authorized Agent: John Stanaland
Work Phone: (949) 698-1302
Agent Address: 1833 South Coast Highway, Suite 210
City: Laguna Beach
State:CA Zip Code: 92651 Agent Email Address:
Escrow Company: Key Escrow, Inc. Escrow # 004886 -BR
Escrow Address: 450 Newport Center Drive, 230 City: Newport Beach
State: CA Zip Code: 92660 Escrow Phone: (949) 698-1960
Email ReportTo: brand i@keyescrow.com
for Inspection Call (Name): Direct Phone:
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELOW)
or
violations are discovered I will be responsible to correct said violations.
Owner/ Agent's signature to authorize inspection:
Date:
Owner/ Agent's signature to decline inspection: �r"�n 9�. Eur(iww Tw.�+u. Date:
9/25/2020
Account #2900-5005 ........ ...Make checks payable to CITY OF NEWPORT BEACH