HomeMy WebLinkAboutR2021-0567 - Permit ApplicationCity of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
tqr11 je Q I b- J-100 Civic Center Drive I P.O. Bax 1768 1 Newport Beach, CA92658-8915
RBR# UU ( �J/tt!! www.newportbeachca.gov 1 (949) 644-3200
for Report of Residential Building Records
Please type or Print and complete all information
#of Units: Address L 1 ; ^ � Ci New ort8each State: �Z
PropertyOwner _ , ��( Zip Code:
Owner Address: 4.-.f.�L-&� VAI..7(P.1 1.7rYiy.Q------ City.
State: �I Zip Code: fJ�_1� Home Phone: �—
Owner's Authorized Agent: ,� i�'tA.l� Work Phone:
Agent Address: BAD i Ni" a, -x -f_f c4T city: �_ .QIA�f,(j1/� 4�c-
State:_�� Zip Code:ria)? Q (4b Agent Email Address:
Escrow Company:"�--�'R�' CyIS�( \ C,ti1rb'-10 --- --- Escrow #:
Escrow Address: "�-�� {�.� _— City:
State: -- �l --_--J Zip Code: L '_"y - Escrow Phone:
Email Report to: 1�CJ-\ B,.QQrl�J�i�lh)°``.�iYY� o\.md�tJ� T'1 .,Q.Q 1Q--!'r_.:`1a�-(�.%Yl'1
For Inspection call (Name): Direct Phone:
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELOVA
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