HomeMy WebLinkAboutR2021-0215 - Permit ApplicationCity of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 92658-8915
RBR# `G 6 www.newportbeachca.gov 1 (949) 644-3200
Application for Report of Residential Building Records
.Application Fee: - $194.00' 1 11 11Notice
(Fer AltResidential Buildings) Applicatronswith insufficient fee payment
Reinspection Fee $129.00 111,oeJti6,niplete will be returned
Please type or print and complete all information
# of Units: Address: 355 Walnut Street City: Newport Beach State: CA Zip: 92663
Property Owner: Smith Family Trust Zip Code: E-77
Owner Address: ( City:
State: CA Zip Code: C� Home Phone:
Owner's Authorized Agent: Work Phone:
Agent Address: City:
State: F Zip Code: Agent Email Address:
Escrow Company: LFreedom Escrow Escrow #: 054489 -MM
Escrow Address: 1200 Newport Center Dr., Suite 180 City: Newport Beach
State: CA Zip Code: 92660 Escrow Phone: (949) 644-3939
Email Report to: mm@freedomescrow.com
For Inspection call (Name): N/A 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 l will be responsible to correct said violations.
Owner/Agent's signature to authorize inspection: Date:
OR
Owner/Agent's signature to decline inspection: Jf ♦44�1 ae,n� gYA65NT--Date: 3.23-2I
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
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