HomeMy WebLinkAboutR2021-0400 - Permit ApplicationDocI elMe ID: D92Rne D8-Fccn-4BRGRGFa_eA5a5t 9ACR FS
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units: F] Address: l �-> Ohl .� �� City: Newport Beach state; CA Zip: M'C.-c.1/ I"
pertyClwner:CC � } C_ ,h ff ci(,l Zip Code:
ier Address: City:
'e: CA Zip Code: °--7 Home Phone:
ner's Authorized Agent: _ Work Phone: r
:ntAcidress:L��1��'�—� ity: e ?
:e:'--��-4-----� Zip Code:
Agent .Ema Address:
,owCompany:
V
row Address: ) 'l— /'
te: Zip Code:
Report to: E `-%
Inspection call (Name):
Escrow #:) / S
City: >�C
Escrow Phone: .AI.19
Direct Phone:
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELOW)
I authorize inspections and re -insp'e'ctions ofthe property lis#edM'abd[understand ct if B
hauilding orZoning +.
violations are d iscovered 1. will be responsible to correct said violations
Owner/Agent's signature to authorize inspection: Date:
DocuSi9ne/dOO RR
Owner/Agent's signature to decline inspection. Date:
Account # 0105 05 04-5 21040 ..........
Ing_0iWsion\FomS\RSR_9-1648
payable tiVC17-Y OF NEWPORT BEACH