HomeMy WebLinkAboutR2021-0187 - Permit ApplicationDocuSign Envelope ID: B2BDE9A8-5D87-4F83-BF25-54185EB2F53B
Print Form City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
tW2[,Ok/ O Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 92658-8915
RBR# `6T wwwvoewportbeachca.gov 1 (949) 644-3200
Application for Report of Residential Building Records
Application Fees: Single Family Res/Condo (tunit)- $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: 212 East Bay Avenue City: Newport Beach State: CA Zip: 92661
Property Owner: 212 E. Bay Avenue, LLC
Owner Address: City:
State: CA Zip Code:
Owner's Authorized Agent: Jami Lynn Sepulveda
Agent Address: 450 Newport Center Dr., Ste. 100
State:CA Zip Code: 92660
Agent Email Address:
Zip
Home Phone:
Work Phone: (949) 717-6000
City: Newport Beach
Escrow Company: Key Escrow, Inc. Escrow # 005395 -BR
Escrow Address: 450 Newport Center Drive, 230 City: Newport Beach
State: CA Zip Code: 92660 Escrow Phone: (949)698-1960
Email Report To:
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.
violations are discovered I will be responsible to correct said violations.
Agent's signature to authorize inspection: Date:
Agent's signature to decline inspection: Le Date:
3/12/2021
Account #2900-5005........... Make checks payable to CITY OF NEWPORT BEACH
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