HomeMy WebLinkAboutR2022-0047 - Permit ApplicationPrintForm
City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
�1 �-00f�-100 Civic Center Drive I P.O. Box 17681 Newport Beach, CA92658-8915
RBR# www.newportbeachca.gov 1 (949) 644-3200
Application for Report of Residential eunaing Kecoras
Application Fee:. - $198.00 Notice:
(For All Residential Buildings) Applications with insufficient fee payment
Reinspection Fee $131.00 or incomplete will be returned
Please type Or print and complete all information
#ofUnits: � Address: e[Q� VLA, V4V-0 'City: Newport Beach State; Zip:
: ,b c:�
PropertyOwner: SI'1 no `Y�Z'h I Zip Code: rial Le U3
Owner Address: City: ��t v po r4riC- K -
2.O �( �Iq (cd� � �
State: CA Zip Code: q (t -&-6 Home Phone: 'l i 4 --14.3-46 �Q s -
Owner's Authorized Agent: P-1 Ci a( �Z_ Work Phone: 11l ck -Z �t 3- d S S-
Owner's
Address: I t`L(d'-tl ,L --h 16(U(j \o(o City: -t+ IArt�-•in� C�l�'�_
State: ,9, Zip Code: �2l¢ ie 3 Agent Email Address: CG -C- H I �@_2_ fa C q 4 ( C.
Escrow Company: A4vr-A,Q teS L)ra � Escrow #:
Escrow Address: i�4i 1 b 1 A Sk (() 3 City: LA4ktYt, GSC.
State: (mak Zip Code:KI(eII/p
Email Report to: I (y`tin6i43 & A AWA
For Inspection call (Name):
Escrow Phone: I -11 -( - q (0 QL - of ei --vCi
n.ee-,5L.v-aua,C-4rv�— (-LCA4Au(Lc2-er5wtaI),vtti
Direct Phone:
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELOW)
1 authorize inspections and re -inspections of the property listed above. I understand that if Building or Zoning
violations are discovered I will be responsibleto correct said violations.
Owner/Agent's signatu re to authorize inspection: Date:
Owner/Agent's signature to decline inspection: �C v e: 'e)-Z-
Arr-ount # 01050504-521a'4e .............. Make checks payable to: OrYO RT BEACH
Buildjn Divislan\F.1W\RBR_7-131