HomeMy WebLinkAboutR2021-0568 - Permit ApplicationProal roan . City of Newport Beach W
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
t j6 �®O'n4� 100 Civic Center Drive i P.O. Box 1768 1 Nevlport Beach, CA 92658-8915
1113110 VJ9, — `J--- www.ric,.wi)ortboachca.gov 1 (949) 644-3200
Application for Report of Residential Building Records
A,py_I cation_Fec_- $198.00 Notice:
(For AliResidential Buildings) Applications with insufficient fee payment
Reinspection Fee $13.1.06 or incomplete will be. returned
Please tvpe or-print,and.comoI etc all information
tl of Units: Address: jam ///.) -//-/,
/S. -/t, �l /S im,City: Newport beach - slate: CA Zip:F
Propr.. rty Owner: /-/ill �! �C� t-.'�/�%i%G C��"��tr/l Lip Code?: —
Owner Address:' City /LI �
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State: ICA Zip Code: �� ,.z!y - Hume Phone: F
Owner's Aufluo?ized Agent: I r Work Phone:
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/l�YfCiiYrte/'Cf_S?ate: I / Zin Code: /„/%�'�"��� _ ��
E`ifrUw t.nm piny;(Escrow It: 'T
cscrnw Address: ! / ! `-.t lu_�.(._/(.,rr4GJ�U%T. �—Cr%'i�J1L •�”-✓� City-
state: `f Zip Code: "% l �l Escrow Phone:/
4ErnailReport to:
For Inspection call (Narne) I Direct Phone:
CONSENT TO INSPE-CT„{f ORM MUS( 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 he responsible to correct said violations.
Owner/Agent's signature to authorize inspection: Date:
OR
Owner/Agent's signature to decline Inspection: KIkCE -__.. Date:
Account it 01050504-51:1.040 ............ ...-make checks payable to: CtTY OF NEWPORT BEACH
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