HomeMy WebLinkAboutR2021-0467 - Permit ApplicationRECEIVED 9y
Print Form City of Newport Beach COMMUNITY
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION JUN 2 3 RECD
2fi �� U 100 Civic Center Drive I P.O. Box 17681 Newport Beach, CA92658-8915
RBR U www.newportbeachca.gov 1 (949) 644-3200 p DEVELOPMENT O.r
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Application Fee: - $194.00
(For AIIResidential Buildings)
Reinspection Fee $129.00
OT Residential uunciing Records �MNFn,unRt"
Notice:
Applications with insufficient fee payment
or incomplete will be returned
Please type or print and complete all information
ttofUnits: Address: Grp/�i! n� City: Newport Beach State: CA Zip: T6®
Property Owner: V(a 2-a f)ktj P"Lo ItZC
Zip Code: Fq i;o Q
Owner Address: 2 5 �� G 1— City: &-C)nc e
State: CA J Zip Code: qZ�%� Home Phone:[G/ir g �' 7/5—
Owner's Authorized Agent: r✓l Work Phone:
Agent Address: City:
State: F Zip Code: F Agent Email Address:
Escrow Company: (.-Cl�UTI RY-t 1EjC:-jbL0 6 VO()p ^OG Escrow N: 1173 f7Z-,7 ,P
Escrow Address: /3lh �j/� y� S r�l� City:
State: I Erf-) Zip Code: ! ZZ rD Escrow Phone:
Email Report to: , 3a?PA j d O(J Es5-Cl l) �04r GM
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. l understand that if Building orZoning
violations are discovered I will be responsible to correct said violations.
Owner/Agent's signature to authorize inspection: Date:
Owner/Agent's signature to decline inspection:
Bulldin�Divisfon\Fo ms%RBRJaa2o
OR
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Account If 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH