HomeMy WebLinkAboutR2021-0249 - Permit ApplicationPrint Form City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
�202�® oL/M 100 Civic Center Drive P.O. Box 1768 1 Newport Beach, CA92658-8915
RBR# U www.newportbeachca.gov 1 (949) 644-3200
Apwiicaiiuri Wi, Repuri ul Residei7iiai uuiidikig Recutds
Application Fee: - $194.00 Notice:
(For AIIResidential 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: _ Cit New ort Beach.: State. CA
OwnerAddress
State:CA. Zip Code: YAO -5,7
'ST
Zip Code: �L.... �.
City:
Home Phone.: 9y. �%Ov,Gs6
Owner's Authorized Agent:
l/M�'\
Work Phone:
For Inspection call (Name):
// Direct Phone:
—.
Agent Address:
7
City:..
State:
Zip Code: % G _ Agent Email Address:
Escrow Company: �. _. Escrow #: _. _..
Escrow Address: �i t
State: Zip Code: Escrow Phone:
Email Report to:
For Inspection call (Name):
// Direct Phone:
CONSENT® O INSPECT (FORM MUST BE SIGNED & DATED BELOW)
I authorize inspections and re -inspections ofthe 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:
OR
Owner/Agent's signature to decline inspection: Date:
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
Building_ Division\Forms\RBR_7-30-20