HomeMy WebLinkAboutR2022-0049 - Permit Application?F- Gm
COMMUNITY
DEVELOPMENT
JAN 3 12022 City of Newport Beach
CITY OF COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
Ip/1,oll�l �� �1 C� enter Drive I P.O. Box 17661 Newport Beach, CA92658-8915
www.newportbsachca.gov 1 (949) 644-3200
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Application Tor KeporL oI RCDILICI ILIGI ouuuu.g Mi K uo
: ,4vo6cation Fee::- $: 141 •Notice:; .:
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A licatrons;"h.insuifcrent•f�@rpayinent �rir. All4tesideritE�4.Bui{dings)' P,P,
Rernspection Fee:$.I29:�0: _ „ . or• ibcprnplate will:6e:n.eturued:
Please type or print and complete all Information
# of Unitr: M Address; 3O -V-.. (?(W : aty: Newport Beach. State:. Flip: 6r Z�Q
Property Owner. n Vet L 1.
Owner Address: City:
State: L� Zip Code: I f /A'/1 M CJS Home Phone: t{a -Lc) cc)
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Owner's AUthorized Agent:�VY ' Work Phone: 33
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Agent Addrress� v IK S V City; N
State: Trp Code: @ Agent Email Address: 4 - •bAv
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Email Report to:
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For Inspection call (Name); Direct Phone:
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELOW)
hautFrorrze inspectrons.and re-iiespection'-af.'the property I?sted above. I understa:ndthat.if Buiidingorloning.
vialatiorasarediscovereda \niil]�be:responsihl'e.to correcrsaid vinlatinns.
Owner;4g�nt'ss9gnature•to•authordie-rnspecti'an:
Owner/Ageat''ssignature•todeciine.inspection: Date:l: r
a,ern.nr tt n1nS0SO4 421040 .................Make checks oovable to: CITY OF NEWPORT BEACH
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