HomeMy WebLinkAboutR2021-0579 - Permit ApplicationPrint Form City of Newport Beach �6,,CLIVED&�,
COMMUNITY DEVELOPMENT DEPARTMENT COMMUNITY
V1 BUILDING DIVISION DEVEI.010MENT
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 92658-891,5AU G 1 22021
RBR# www.newportbeachca.gov 1 (949) 644-3200
Application for Report of Residential Building Records CITY OF
Notice: 1---kP0RT F01611
(For All Residential Buildings) Applications with insufficient fee payment
Reinspection Fee $131.00 or incomplete will be returned
Please type or print and complete all information
#of Units:_Address: g.0�, ,o Vj ,(2aNi✓Y\.... ity: Newport Beach State: CA Zip:.,gZ�ZCJ.
Property Owner: .-(: �WI(...t�. VY..I.I^1��A_ J tom...._. ...�_/�D:,,� ,2 rZip Code: �i0��
Owner Address: QI� ....... 100Y .Is a.A� Di�..�.. City: 1. twe(rf-f 1.:7. �,',V1.. _..._.
State: CA Zip Code: -1�1 Home Phone: 1, 01 49 . 5(6M 9 K_z.
Owner's Authorized Agent: l pouut q M & V -41A I� a /',1,� Worrk� Phone: 014`1 ♦. 2O2„ 9 :1(0 Cl
Agent Address: Lk Go Y )ewPU� CAY2 VD) . Wity: t1�i,e�{�iZ l-• I�C�(/� "7
State: I Zip Code: i3� 2(p (QO. Agent Email Address: y(�A
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Escrow. Company: ?AAd4Mt VY_.Q tE�S.(J-"_tk4-, Escrow #:I '2i.,,, tI 3C,.4—DM
Escrow Address: 19 4Od ( r6l; Ia d KA City: T")
State: Ca Zip Code: - J(P 12— Escrow Phone: q LI C - 6j 2 — 190 O
Email Report to:' IJwe6� b.I a c V -M Q{re.,eS G- r -ID W, coyy-N
For Inspection call (Name): V. 1. a __.. 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:
Owner/Agent's signature to decline
Account # 01050504-521040 .........
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Date:
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