HomeMy WebLinkAboutR2021-0270 - Permit ApplicationDocuSign Envelope ID: 6601EDF7-EFOD-476C-875E-422A78221596
COMAvIoNay1
Prnt Form City of Newport Beach DEVEI'Opmc
COMMUNITY DEVELOPMENT DEPARTMENT APR 08 2021
BUILDING DIVISION
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/� rt�Io�II L/j, Pl 100 Civic Center Drive I P.O. Box 1768 Newport Beach, CA 92658-8915
RBRI 1�(/ '[ O www.newportbeachea.gov i (949) 644-3200 `'I y OF
for Report of Residential Building Records "ORT
Application Fee: - $194.00 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
i y State: CA :zip: 92625
tfofUnits: Address: 4721 Courtland Drive City; New ort Beach � ��
PropertyOwner: PSG Capital Partners, Inc., a CA Corp.', Zip Code 92618
Owner Address: 16441 Scientific Way City: Irvine
State:^_ Zip Code: 92618 Home Phone: 949-233-4669
Owner's Authorized Agent: Bob Gino Work Phone: 949-584-9070
Agent Address: 33522 Niguel Road
State: FCA Zip Code 92 62 9
City: j Monarch Beach
Agent Email Address: I bobgino@me.com
Escrow Company: The Escrow Source, Inc. Escrow #: 9011 -KS
Escrow Address: 27612 La Pa Road Suite D City: Laguna Niguel
State: FCA Zip Code 92677 Escrow Phone: 949-305-0888
Email Report to: raleigh@theescrowsource.net
For Inspection call (Name): I 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 Buildingor Zoning
violations are discovered I will be responsible to correct said violations.
Owner/Agent's signature to authorize inspection:
OR
rD.cu Signed by:
Owner/Agent's signature to declineinspectiom. I 6D
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Date: i
Date: 4/8/2021
Account # 01050504-521040 ................. Make checks payable to: CITY OF NEWPORT BEACH
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