HomeMy WebLinkAboutR2022-0193 - Permit ApplicationPrint Form. City of Newport Beach
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COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISIONT'
_ 100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-8915 APB 0 Zp��
RBR#���, �' ���� www.newportbeachca.gov 1 (949) 644-3200
Application for Report of Residential Building Records * ..
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Application Fee: - $198.00 Notice: T
(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 F Address:da k 10.11xt co-vufi- All's � City: NewportBeach � State: CA Zip
PropertyOwner• �.Q,l)y (,(,YtYI CA,Im' � 1 Zip Code.
Owner Address
ate.. Kl�ll Cnul gr115 City
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State: CA ,J Zip Code `off Wi (p, Home Phone ? D U� . C.�? (B
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Owner's Authorized Agent: (�(n.!")(ll (,' hvi)SIk-I _. _ .I Work Phone:
Agent Address: W r.: __CCM ti City:._ l
State: � ZipCode �J, � ���
j _ „� 95V �,�j Agent Email Address: t q, i ketJ'S'w'e Ili"
Escrow Company: pll�+C cOGoI()eC�bvd ...... Escrow#:.,
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Escrow Address: ,�' /� City:._..P
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State: C.a- Zip Code: Escrow Phone: CJ<;7 , Gi l __ q
Email Report to:
C E SC L-W cam
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For Inspection call (Name): /1 �I �n I _ �� _. _- _ _ Direct Phone: 7) 7 . 0
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 t�th ipecEian" Date:']
OR
Owner/Agent's signature decline) pection:
Date:
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
Building_Division\Farms\RBR 71-21