HomeMy WebLinkAboutR2022-0146 - Permit ApplicationDocuSign Envelope ID: F65DCDD0-8C6D-4A8F-97C0-4806084537DD
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COMMUNITY
DEVELOPMENT
Print Form City of Newport Beach MAR 18 2022
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION CITY OF
''�^t� }1 100 Civic Center Drive P.O. Box 1768 1 Newport Beach, CA92 8915
RBR# �ZV`VU—QH0 www.newportbeachca.gov 1 (949) 644-3200 PORT SEDC
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 incomplete will be returned
Please type or print and complete all information
It of Units F�F Address: y�,.,.--- --- ._ ___.._..__....._.__ City: Newpart_Beach State: CA Zip:,_9�&5J._�
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Owner Address: 12796 East Si l axo Rd
State: CA Zip Code: P3619
_ Zip Code:
City: Cl ovi s
Home Phone:
Owner's Authorized Agent: �/�/ ���^ p..� Work Phone:
Agent Address:��?_/,%le-A i«!7/✓(/I -S6 P-7-0-1 City:... AS? ill G ... ..
State: �G Zip Code: 19Agent Email Address:
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Escrow Company: tj4RC'ej'w)'? (f� V �i_ Escrow It:
Escrow Address: ly��a ;EwI RCHILp rid % City:
State: Cr Zip Code Escrow Phone: 4vg,6r%-/ /Do '
Email Report to:I.. .f. -e �q-%�j�a cl-4mo /,&- c- g`,os�vv
For Inspection call (Name): "D 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 inspection:Date:F
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Owner/Agent's signature to decline inspection: —�ViF QIt ar Date: 3/17/2022
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Account # 01050504-521040 ................. Make checks payable to: CITY OF NEWPORT BEA CH
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