HomeMy WebLinkAboutR2021-0245 - Permit Application.. fGG iVED Oily
Printorrn City of Newport Beach coMi'JiUNITY
COMMUNITY DEVELOPMENT DEPARTMENT 0EVFL0PMEN1
BUILDING DIVISION i�
100 Civic Center Drive I P.O. Box 17681 Newport Beach, CA92641%ii52 2021
RBR# �y ✓ www.newportbeachca.gov 1 (949) 6443200
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Application Tor Report of Residential Building Reco s mac,
ARPlication Fee: - $194,00
(For All Residential Buildings) Applications
1 Applications with insufficient fee payment
Reinspection Fee $129.00 or incomplete will be returned
Please type or Print and complete all information
#of Units: F—Address: 1 20212 �JVICW City: Newport Beach state: CA Zip: q2u 95
Property Owner. ie,Gy I Ree- MomB Zip Code: F—
Owner Address: 9U2"j-2_ V1tW �N-e City: I Ncwr, +
State: CA Zip Code: I dgsuLC6 Home Phone:
Owner's Authorized Agent: lob 6 CD I lo Cc, 1 ® Work Phone: I qy1 , sib , L4
Agent Address: I W �^�' �'� , 'IC>. ov.& aP Jt. 6k
State: I "' " I � �' Zip Code: �-Loub Agent Email Address: `aicolI L*cC 10 P--> V i A kz�;c N ,
Escrow Company: ITI&AP6
0& Vj 11A C, Escrow #: Us 41&1 k -v -
Escrow Address: 2-1 9#41111 GT_ STe -33b City: I�Kb?-Mal
State: Zip Code: Escrow Phone:f—7114. *5.1 U �
Email Report to: Vepv. ISG .
For Inspection call (Name): PDL_ -v, C® I U M, LJ Direct Phone: c1L _-s, lJ
CONSENT TO INSPECT IFORM 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 1 will be responsible to correctsaid violations.
Owner/Agent's signature to authorize inspection: Date; F—
O
Owner/ gent�aturetodecline inspection: Dater �(
Account # 01050504-521040 ................. Make checks payable to: CITY OF NEWPORT BEACH
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