HomeMy WebLinkAboutR2021-0345 - Permit ApplicationPrint Form City Newport Beach of ort ornwu�IrY
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COMMUNITY DEDIVISION VELOPME DEPARTMENTBUISAY (,9 2OZy
p()qo q j p{ 100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 92658-8915
RBR# �l /(J l "ll www.newportbeachca.gov 1 (949) 644-3200
Application for Report of Residential Building Recorc�l>oRr"��
Application Fee: - $194.00 Notice:
(For All Residential 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: 5 Clear Water City: Newport Beach State: CA .Zip: 92657
PropertyOwner:l ValbuenaFamily Trust
Owner Address: 13334 E. Coast Hwy #365
State: CA Zip Code: 92625
Zip Code: F
City: I Corona Del Mar
Home Phone: 714-309-2366
Owner's Authorized Agent: Mark Williams/JI-SI Corp Work Phone: 949-456-9577
Agent Address: 25909 Pala Suite 100 City: Mission Viejo
State: CA Zip Code: 92691 Agent Email Address: markwilliams4@hotmail.com
Escrow Company: i Escrow #:
Escrow Address: City:
State: Zip Code: Escrow Phone:
Email Report to:
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:
Date:
R
Owner/Agent's signature to decline inspection: J � ate; 1 4/30/2021
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
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