HomeMy WebLinkAboutR2022-0161 - Permit ApplicationOCEIVED 6r
City of Newport Beach COMMUNITY
COMMUNITY DEVELOPMENT DEPARTMENT DEVELOPMENT
BUILDING DIVISION AR 2 8 2022
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-891
www.newportbeachca.gov 1 (949) 644-3200
CITY OF
Application for Report of Residential Building Recordspdt•
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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
#of Units: e2 1Address: 5/S IKIS _ - City: NewportBeachJ State: �Zip:�
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Property Owner: Chdfip* aCP&nS �/ -ell �kJ�t? %/!/S � Zip Code:
Owner Address: /,oqr rj'g' city: Par,-14,(
State: >PA l 1Q zip Code: Q:77► S Home Phone:
Owner's Authorized Agent:pb,py f' /,(/q�f�� I work Phone:
Agent Address: 8py,_CS%9�{^2-Al
fj)R_lt�llN�it.�%F„„amity: /SHOD
State: L Zip Code: Z�(�O J ggent Email Address: .60b {/q fj'pyi
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Escrow Company: i Escrow #:
Escrow Address: I7_00_N 10r/ ry �._v_✓.___.n�__'?1 J City:
State: Zip Code Escrow Phone: F94 c L-- _- -
Email Report to: bob G</ *6v) 40 hhh se I? ---- -------- .___.__- --------.....--------- ----------a
For Inspection call (Name): J 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: INSpEC7710N OgGIDate: —
OR
Owner/Agent's signature to decline inspection:ML
Date: D3a��
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
Bu11d1ng_Div1s1on\Forms\RBR_7-1-21