HomeMy WebLinkAboutR2022-0054 - Permit ApplicationCity of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
Ips nq��6 100 Civic Center Drive I P.O. Box 1768 Newport Beach, CA 92658-8915
RBR# FINL www.newportbe2chca.gov (949)644-3200
Application for Report of Residential Building Records
Application Fee: -$198.00 :;Notice-
(For All Residential Buildings) Applications with insufficient fee payment
Reinspection Fee $131.00 or into`mpiete. Will be returned
Please type or print and complete all information
# of Units: Address: 1503 Cornwall Lane City: Newport Beach; State: CA Zip: 92660
Property Owner: Derick Borean and Stephanie Borean Zip Code:
Owner Address _-_-.-� City:
State: CA Zip Code Home Phone:
Owner's Authorized Agent: Work Phone:
Agent Address: City:
State: Zip Code: E-, Agent Email Address:
Escrow company: Freedom Escrow Escrow #: 055155 -MM
Escrow Address: 1200 Newport Center Dr., Suite 180 City:Newport Beach
State:Cq Zip Code: 92660 Escrow Phone: (949) 644-3939
Email Report to: mm@freedomescrow.com
For Inspection call (Name): N/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 inspeftion: Date:
OR
Owner/Agent's signatureto decline inspection: Date:
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Account # 01050504-521040 .................Make checks payable to: CITY OFNEWPORTBEACH
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