HomeMy WebLinkAboutR2021-0259 - Permit Applicationrg,CEI VEp !Tr
f'rnt 1 ortn City of Newport Beach COMMUNITY
COMMUNITY DEVELOPMENT DEPARTMENT 1TFVELOPMENT
BUILDING DIVISION APR 0
2�2 p 100 Civic Center Drive I P.O. Box 17681 Newport Beach, CA92658-8
RBR# l www.newportheachea.gov 1 (949) 644-3200
CITY op
Application for Report of Residential Building Rrds __,&\
Application Fee: - $194.00 Notice:
(For Ali Residential Buildings) Applications with insufficient fee payment
Reinspection Fee $129.00 or Incomplete will be returned
Please type or print and complete all Information
# of Units: Address: � 15!(ifQ� Q City: Newport Beach State: A Zip: (i
Property Owner.) e-V1L S6�b ✓l i x—
Owner Address: LlZD 60 W)W, , +
State: F Zip Code: 3
UL -
a VD city:
Zip Code:R�3
Home Phone: I CH4-30b S 1SZ
Owner's Authorized Agent:
I r ida t
�V1�-1n.c�
Work Phone:
Agent Address:
_?ql 1
ViCA- Ucto
a-bi _
City:
Pr)
State: Zip Code: ( gZ-QQ j Agent Email Address: --b
Escrow Company:
Zn + I /; , Escrow #: -� 1Gj (3—
Escrow Address: �0t UbO4— 7 i City: La II_ I
State: C�— Zlp Code: Escrow Phone:! tri l/1Z,�ti z5$
Email Report to: tntCkt-� k-- 5�-✓t.nILj25C✓0w Com t
For Inspection call (Name): 1 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 Building or Zoning
violations are discovered i will be responsible to correct said violations.
Owner/Agent's signature to authorize inspection: Date: F—
OR )
Owner/Agent's signature to decline inspection: �i �C�' s' Date: t
Account;; u1050504-521040 ................. Make checks payable to: CITY OF NEWPORT BEACH
StiiMIn�DNisivn\mss\�fl_3a0.30