HomeMy WebLinkAboutR2021-0210 - Permit ApplicationDocuSign Envelope ID: 70A66EB3-OD12-4AF3-A46F-BO2913588508 f 6-, —
xkw� City of Newport Beach
,SPnnt Fnrm' 1,
COMMUNITY DEVELOPMENT DEPARTMENT j
BUILDING DIVISION V �I
100 Civic Center Drive I P.O. Box 1768 j Newport Beach, CA 92658-891
RBR# /•¢r www.newportbeachca.gov 1 (949) 644-3200
i Residential Build Records
Appllcat on for Report of Res de ina ec
# of Units: Address: y: Newport Beach'j State: CA Zip: ) .
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Property Owner:
Ownei
State:
Zip Code:Afc.a[� -01
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Home Phone: �—
Owner's Authorized Agent: Work Phone:
AgentAddress f City:
State: ; Zip Code ,.%j2�"({ Agent Email Actress:
Escrow Company: r } Escrow #
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Escrow Address:
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State: I CZip Coder Escrow Phone
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
A2
Owner/Agent's signature to decline inspect I �g-
Date:
Date:.
Account # 2900-5005 ................. Make c1"iecks payable to CITYOFNEWPORT BEACH