HomeMy WebLinkAboutR2022-0026 - Permit ApplicationCity of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
Vqq M BUILDING DIVISION
G ��(y 7,f �y00 Civic Center Drive ( P.O. Box 1768 1 Newport Beach, CA 92658-8915
www.newportbeachca.gov 1 (949) 644-3200
Application for Report of Residential Building Records
li Application Fee: - $194.00 Notice:
(For All Residential Buildings) Applications with insufficient fee payment
Reinspection Fee $129.00' or incompiete'will be returned
Property Owner: imp ,/t/ ,. 1 V i _a„ I , &— ____ Zip Code: F'�_—_
Owner Address: a�1./e.v w.n �, A!.... city:
State: ICA Zip Code:F4iZ(o3l`-Y.. HomeePPhhoo"nee:
Owner's Authorized Agent:
�/%(-- 8 p�/;,f�/'�f�' � , Work Phone: I RL4 +-
Agent Address: j...1��r�4V...._. y6��..' `a �`, ..''vv •v'P.v. _. City: _i...+
State: F A� _ Zip Code: c (,00 /Agent Email Address:1. Rn }iOJli1�. . iAly't�al$ <C^
Escrow Company: 5e/i,1 Escrow #:
Escrow Address:. �/yVg 7....... HkA-L-` _241K ..-IC.........., City: �'_L /,6�rd44- 41115���///���
State: G -� Zip Code: �Escrow Phone: GL 1 (�
Email Report to: ( Ml. 1� tL7 -* Se.i!4,ha,,� - `"i—o.l ('R ° n _
For Inspection call (Name): t� % 11 Direct Phone: F—
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 inspection:
Bu11dfng_O1o190A\F0,ms,RBPJd620
OR
Date: �—
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
Please type or print and complete
all information
#of Units: Address:.
i�
°^(i,�,,,,� �i,,ilm. �.1
City: Newport Beach
State:Zip:�^J//
Property Owner: imp ,/t/ ,. 1 V i _a„ I , &— ____ Zip Code: F'�_—_
Owner Address: a�1./e.v w.n �, A!.... city:
State: ICA Zip Code:F4iZ(o3l`-Y.. HomeePPhhoo"nee:
Owner's Authorized Agent:
�/%(-- 8 p�/;,f�/'�f�' � , Work Phone: I RL4 +-
Agent Address: j...1��r�4V...._. y6��..' `a �`, ..''vv •v'P.v. _. City: _i...+
State: F A� _ Zip Code: c (,00 /Agent Email Address:1. Rn }iOJli1�. . iAly't�al$ <C^
Escrow Company: 5e/i,1 Escrow #:
Escrow Address:. �/yVg 7....... HkA-L-` _241K ..-IC.........., City: �'_L /,6�rd44- 41115���///���
State: G -� Zip Code: �Escrow Phone: GL 1 (�
Email Report to: ( Ml. 1� tL7 -* Se.i!4,ha,,� - `"i—o.l ('R ° n _
For Inspection call (Name): t� % 11 Direct Phone: F—
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 inspection:
Bu11dfng_O1o190A\F0,ms,RBPJd620
OR
Date: �—
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH