HomeMy WebLinkAboutR2022-0175 - Permit Application, eer,OVED vy
Print Form City of Newport Beach COMMUNITY
COMMUNITY DEVELOPMENT DEPARTMENT DEVELOPMENT
BUILDING DIVISION �SR8916
pdd 2022
(� 100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA928
RBR# �Vl� www.newportbeachca.gov 1 (949) 644-3200
CITY OF
Application for Report of Residential Building RecoilsoRre�a a\
:.
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: ,y I' Address; 7 f! ;Cit . Newport /
/ /'r.. htt_.__'l All" t _, y Beach I State CA ;,Zip. T-J�G�t7 -�
Property Owner: ,44AI
Zip Code:����
Oat erCdress:7.1Qcity:
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i Zip Code Home Phone:
Owner's Authorized Agent: I J_T rte^ V R 94,0U Work Phone:
Agent Address: A dot/t S-74 pi's 4 City
State: Zip Code: 4��(i(1 ,..�, Agent Email Address:
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: INSPECTION Date:
D�LINED
Owner/Agent's signature to decline inspection:/�� C/ L�/fi��, Date:
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
Buildin�Division\Forms\RBR 7-1-21