HomeMy WebLinkAboutR2021-0208 - Permit Applicationit'Form City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
6A 100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 92658-8915
LU lHqg www.newportbeachca.gov 1 (949) 644-3200
Application for Report of Residential Building Records
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
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Address: prt ac�' State: [C7A�Zip:
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Property Owner: )-',P Zip Code:
Owner Address: City:
State: Zip Code:Fq-Sc,,-T, Home Phone:
Owner's Authorized Agent: Work Phone:
Agent Address: city:
State: Zip Code: Agent Email Address:
Escrow Company: lAfV,,---f zw Escrow #:
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Escrow Address :
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State: Zip Escrow Phone:
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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. 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:
0
Owner/Agent's signature to decline inspection: we � Date: /-7:?'
Account # 01050504-521040 ................. MAke chftks payable to: CITY OF NEWPORTBEACH
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