HomeMy WebLinkAboutR2021-0271 - Permit ApplicationDocuSign Envelope ID: 09DF3053-5FCE-4002-9959-FD810B9351 FB
RKV oil
City o'
COMMUNITY 0
100 Civic Center Drive I P
www.newp
Application for Repot
Application Fee: -$194.00
(Fpr AllResidentialBuildings)
Reinspection Fee $129.00
Please type or pt
i/ of Units: I Address:
Cpl?AGN?TyOL
kllvp
;T BFPG�
feepayment
ad .. . .
a' :92660..__)
Property Own er:---..._.Ann.....S:.-_Macken.z.ie
Zip Codo:
..-•----.-- - _..... ._. _.-.----__._.�
Owner Address;
_,791.61 _Sierra_ Maria Road. City:
Irvine
State: F7
Zip Code 92603 I
Home Phone; 99 677 9282
Owner's Agent: Jc19tk.D hT,7..7.1S�.ItSOtI_ J
Worl<Phone: 4.9. --5,7.1.Z_-...,_._
tAddrAuthorized
Agegent Address:
5r z99 Altan_.P.arkwa
I City:
c
State: CaZip
Code: 92660 Agent Email Address;
�
Iden j.am73-@gmai-1-com....____
Escrow company:
-I Escrow 71: N21 -00438 -TE r
Escrow,_Technolo,�ies- _ - _
Escrow Address:
35eCity:.N�pot.,Beach,,,__._.
State:
CA J Zip Code:
__._•-------
92660
Escrow Phone:--
.--
-_-.----•-.-
Email Report to;
For Inspection call (Name); Direct Phone; I
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 orZoning
violations are discovered l will be responsible to correctsald violations,
00cu9gned0y:
Owner/Agent's signature to authorize Inspection: W0At*4dr Dater
B.leh3
g0FOenlre ..
Owner/Agent's signature to decline Inspection:
Building DlNdan\FOIme\RDR_7.3030
Date:�W�Y
1
Account 7101050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH