HomeMy WebLinkAboutR2021-0223 - Permit Applicationfoim:, City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT CUNC+•7UNITY
BUILDING DIVISION D[ o-cPMENi
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-8915 MAR
www.newportbeachca.gov 1 (949) 644-3200
Application for Report of Residential Building Records cry0i
Application Fee: - $194.00 Notice: 44" rr;T 4a`e.r�C;2
(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
#of Units: �, Address: 3,51 aa`f City: Newport Beach. State: CA Zip:
...q
Property Owner. Cvydba. f�u. ),m et> O, I.. _1 oL /AJe q. j,y''-�,)),,,,// / 7 Zip Code: 4' 1
Owner Address: -34- apL + ReeOAC t -WN City: 1 lV,-cGPivyry'-.�'.. (,DGS„T --. ..
State: CA.,.. Zip Code: av-w? . Home Phone: I Vlv l — qj j
Owner's Authorized Agent: _.I r lPil ��� _ Work Phone: Q' DV—FV-9
( I LY 1,,,, v .. � %/' l r o 0 3
Agent Address: I'`%vv- VM I rm—a11 ANG Am w�ty. IYVi%Ie
State: CIA Zip Code: q(y Agent Email Address:
vYL3oUfrTrfr� Eti .alv�df.�l.cdm�l
Escrow Company: ath!4)•E?Escrow #: Q23DDD—0�,,,,,
Escrow Address:' Cit
6� f�un,far�c” Ar , Su,ae 3 y 5cth Ma�n� _
State: C Zip Code: Fo,f/ Vs- Escrow Phone:
Email Report to: I in 3T1 -D M 0 9Y114U-1 r tawL--
For Inspection call (Name): M� � j wAn _ _.._ Direct Phone: �qyp :3D�. CSL
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 corrctsaid violations.
i
Owner/Agent's signature to authorize inspection:,r
OR
Owner/Agent's signature to decline inspection: Date:
Account # 01050504-521040 .................Make checks payable. to: CITY OF NEWPORT BEACH
Building Division\Forms\RBA 7-3020