HomeMy WebLinkAboutR2021-0253 - Permit Applicationp
City of Newport Beach rvwr�llnitw
COMMUNITY DEVELOPMENT DEPARTMENT D l V1,,[ 0PN1K:N1'
BUILDING DIVISION pp � 9 2i.
100 Civic Center Drive I P.O� Box 1768 1 Newport Beach, CA926-615
RBR# 1� L 6 www.newportbeachca.gov 1 (949) 644-3200
Application for Report of Residential Building Recqrds x
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: F Address. a City: Nwort Beach State: Zip:
ICA :
FV
W2,7-
Zip Code: �„r
Owner Address: FjQ 5 -� - _ city: �� � ��� n�.
State: CA Zip Code: Home Phone:
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Owner's Authorized Agent:Nv �d� "W 1st Work Phone: 3t V .' �2 . y y%q
Agent Address: 2�1`-� Yt01�� IJr�V2 City �OS A,,., -Las
State: FC�Zip Code: q00(oco? Agent Email Address: V
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Escrow Company: O �/ p ESC1!OuJ Escrow #: N ope. '-fer i
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Escrow Address 19 52t{ NorA-hc% Sk, lAvt '+ __ -i City: tJ-r-tW(iatq-
State. Zip Code: gl` vi Escrow Phone: $l$'-,5qq-018K
EmailReportto. SKAIAIIJ�ovtejue.jeSGrOw.com�'0AVZ1DL-WTk.S&IJ31Dgrnwil•Cowr
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:
OR
Owner/Agent's signature to decline inspection:
Date:
Date: -3 3I o
Account # 01050504-521040 ................. Make checks payable to: CITY OF NEWPORT BEACH
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