HomeMy WebLinkAboutR2021-0168 - Permit ApplicationMM City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
t/�o!) �, �f I Q�00 Civic Center Drive I P.O. Box 1768 Newport Beach, CA92658-8915
j G l U V www.newportbeachca.gov 1 (949) 644-3200
Application for Report of Residential Building Records
Aonlication Fee::- $:t � 0o Nom;'
(Fn�%SiIk4icte'ntlaf Buildings) Applications with insufficient fee payment
Reinspection Fee $129.66 or incomplete will be returned
Please type or print and complete all information
"i� -c- r kS(? _r`.B I State: CA (Zip: MI -07S #of Units: Address: - �, City' [Newport Beach 7S—
PropertyOwner: � `1., `a�"'f IU'"'i (.�L.. (_-....... Zip Code:
Owner Address: 1-
k.r Oc ✓ �a,. city: i2E•� 'v�-1 f i 1T
State: CA 7 Zip Code: C' - Home Phone: -q
L 41
Owner's Authorized Agent: Work Phone:
Agent Address: J City:
State: Zip Code: ( Agent Email Address:
Escrow Company FCY oah s rr Escrow #: ' Y
Escrow Address:r)(. �O City
State: .A _ j Zip Code: — ��(.�� Escrow Phone: ,y' '3 C( "5 C,1
Email Report to: FT4�C�Of fl;�J fel y
For Inspection call (Name): 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
i violations are discovered Iwill beresponsible tocorrect said violations.
'
Owner/Agent's signature to authorize inspection: Date:—
4�-'
OR /f
Owner/Agent'ssi (Fl/ �I--��--
nature to decline inspection: ! rKl�y I •' 1
g P 'd '"� Date:!
v
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
Building Division\Forms\RBR_7-30-20