HomeMy WebLinkAboutR2020-0927 - Permit ApplicationPnnt Form 16 CGSWED, ENTp � LLQ
City of Newport Beach Comm NT
COMMUNITY DEVELOPMENT DEPARTMENT S E y
BUILDING DIVISION T 2 020 \\
100 Civic Center Drive I P.O. Box '1768 � Newport Beach, CA92658-89
M# www.newportbeacl'ica.gov ( (949) 644-3200
CITY
Application for Report of Residential Building Records c\�,
Application Fee $ 194. 00 - Notice
(For, All R;esidentialBuildings) - ppplicatlans,vithinsuffiilentfeepayment
Reinspection Fee $129.UD or incampiete.will be returned
Please type or print and complete all information
t of Units: Address: [, �..1 �,^ .f �' City: Newport Beach State: CA Zip:
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'ropertyOwnert t.
Zip Code:
)weer Address: Ciiy:! r a�C?
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;tate: CA Zip Code: r Home Phone: %.
Owner's Authorized Agent: r _�, Work Phone:
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4gentAddress: ex? City: 4
;Cate: Zip Code: Agent Emarl Address:
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:scrow'Company:
Escrow Address:
State: Ff
Email Report to:
Escrow#: J'z',� 1
For Inspection call (Name): Direct Phone 1 7
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELOW)
lauthorizeinspections.andre-inspectionsofthepropertylisted;above IunderstandthatifEtuild)ngor2onln'g-
violations are discovered 1 will be responsible to correct said violations.
Owner/Agent's signature to authorize inspection: - Dater -T
OR,
7Owner/Agent's signature to decline inspection: Dater IQ-Z�p�20�'OJ
Account # 01050SO4-521040— .......... ... Make checks payable to: CITY OF NEWPORT BEACH
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