HomeMy WebLinkAboutR2022-0004 - Permit ApplicationCity of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
00(� 100 Civic Center Drive P.O. Box 1768 1 Newport Beach, CA9265"915
RSR# W L _ 1 www.newportheachca.gov 1 (949) 644-3200
Application for Report of Keslaentlal tsuualrlg Kecoras
Avollcatihra F'ee::- $I [cl I� Notice:;
.(•Frir.'All4fesideritEal.Buildings)' Appiicationswith.insufficient•f�e•payinent
RemspeCian F.ee:$129:DD: r orIhIcomplet'e will1e;6ek&r."d'
Please type or print and complete all information
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Property Owner: -,1u7v\ v\ -Q p Zip Code:
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State: CA Zip Code: Home Phone: I qqq Z2,c) ( 10
owner's Authorized Agent: •MiR LAM6N Work Phone: I CT
Agent Address: ` y)v%e City: , -�- 7xa(
State: Trp Code: Agent Email Address: C rl,(M
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Email Report to:
For Inspection call (Name): Direct Phone:
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED SELOWi
t'authct rize inspectrons.andre=iinspection'spf.•the property luted above. I an'derstand-that.if l5u.11ding or2oning.
vialatinnsare.discovered'I v✓.in:be respbnsial'e.to correctsaad viblatrans.
Owner/••Agents§gnature•to-authadie•rnspectl'nn:
Owner/Agent'F,MgnaIdecillne.inspection:/j� Date::
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
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