HomeMy WebLinkAboutR2021-0466 - Permit ApplicationRECEIV,rU
drtMF R" City of Newport Beach CO
a3 soC�? 4; COMMUNITY DEVELOPMENT DEPARTMENT
100 Civic Center Drive I P.O. Box nDIVISION
17 81Newport Beach. CA 92658-8915/(/
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www.newportbeachca.gov I (949) 644-3200
Application for Report of Residential Building Records
Aoa114ation Fee: ' ¢#?3 00 (q Notice:
(For All Resldential Buildings) Applications with insufficient fee payment
Reinspoetlon Fee $ 117.00 or incomplete will be returned
Please type orpr(nt and complete all information
# of Units: l Y Address: g f V b,„ Pj ^\4,,-,
D o- City.-
Property
ity;
Property Owner.I -Od (,t.--4-vq1 i C1,
Owner Addiress: � Jr �'nlV \ _ I12 .
State: CA Zip Code:\J
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City: IC':.yr,.3 Clc.l
Zip Code:1 —
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Home Phone: I c� c (!� _ -7 2-0 _ --i C)5;�,
Owner's Authorized Agent: Jit 1" Work Phone: I -) I Lf -7 3 . 0
Agent Address: i1�o1 I � �1 City: -� Lt
State:W -- ZipCode:C Q Agent Email Address: C,L-(CH A
Escrow Company: Vc,vl"' GC.1 <�4 SL.0 V �1 Escrow#
Escrow Address: lcitQ-1y City: ,--j. L,t, (^��,.� -1A
State: Fa Zip Code: (2I a u 4:y Escrow Phone:
Email Re ort To: ttq� l
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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 tocorrect said violations
Owner/Agent's signature to authorize inspection Date
ORS
Owryer>Agent' signature todedineinspectio x, <Datel
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Account # 2900-5005.................Make checks payable to CITY OF