HomeMy WebLinkAboutR2022-0177 - Permit ApplicationPrint Form
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COMMUNITY
City of Newport Beach DEVELOPMENT
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION APR 05 2022
100 Civic Center wDrive
ewportbe chca.govox l Newport {949) 644-3200 Beach, CA 92658-8815
RBR# CITY OF
Application for Report of Residential Building Recor&l, 501d�
Application Fee: -$196.00 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: NO n�,-1.•1--s i_ City: Newport,Beach-j State: cZip:-e?��ya_.-
Property Owner.' j��•l Zip Code: pp
Owner Address: VcL City:
State: Zip Code: FNHome Phone: q A
Owner's Authorized Agent: �— / Work Phone:
Agent Address: 1-3-333M _tCi e sCs1._.1J_l-i.t)' - 16 Com' __
State: e (�- _ _ Zip Code: l��I Agent Email Address: �• I ' -��
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Escrow Company: tY1ECtCtt.�. �t1e_C Escrow#:
------
Escrow Address:l Zip
Code:
City'
State: e -A-- Code , Q Escrow Phone:
Email Report to:
For Inspection call (Name): �1,� _ .� _ i�m� �� — — 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 orZoning
violations are discovered 1 will be responsible to correct said violations.
Owner/Agent's signature to authorize Inspection: INSPECTION Date:
DECLINEB-
OR
Owner/Agent's signature to decline inspectiore
Date:
nccounc s U.rU�u5U4-sn.u4u.................Make checks payable to. CRY OF NEWPORT BEACH
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