HomeMy WebLinkAboutR2020-0887 - Permit ApplicationCG �Jr
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City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION Sir?
yy��q cit 100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 9265$-8991.
Ram www.newportbeachca.gov 1 (949) 644-3200 r� O?
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Application for Report of Residential Building Records ��9CK
- Application Fee:: -$1. 1 C1 tj � � � � Notice: .
.
(For -AIIlkesidential.Buildings)'- Applicatronswith.insufFcient,fee•payment
Reinspection F.ee: $,T2B:Oaor ihromplete will: be: returned!
Please type or print and complete all information
# of Units: I AI Address: 2 city: Newport Beach State: aZip:�
Owner Address:
State: Zip Code:
IZip Code:.
city:
Home Phone: I qqq Vw
Owner's Authorized Agent: Ah e, IWork Phone:
Agent Address: UO ' C1ity: al
State: Imo— Zip Code: I .I Agent Email Address: s[,I e '5 . V1
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Email Report to: I .t- PLrkZr I CX Y" I
For Inspection call (Name): w Direct Phone:
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELOW)
lauthor,'rze inspections.and.re=imspections of, the property listed above. I understand:that.if Building orZoning.
violations are.discovered:I will be:responsibl'e.to carrectsaid violations.
Owner/Agentfs signature to authorize i;nspectiam pate:.
OR
Owner/Agent'ssignatureto deciine.inspectian: Date,1.1I 1 I FSI
Account # 01050504-521W .................Make checks payable to: CITY OF NEWPORT BEACH
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