HomeMy WebLinkAboutR2022-0197 - Permit ApplicationDocuSign Envelope ID: B40F7F9D-29AO-4AB5-A2F8-83883D69BD21
Print Form
City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
100 Civic Center Drive I P.O. Box W68 Newport Beach, CA92658-8915
RBR#&Q-d I % www.newportbeachea.gov (949) 644-3200
Application for Report of Residential Building Records
Application Fee: - $194.00 Notice:
(For All Residential Buildings) Applications with Insufficient fee payment
Reinspection Fee $129.00 or incomplete will be returned
Please tvi3e or print and complete all information
#of Units: F Address: ' �r e.5 1! City: Newport Beach I State: CA ilip: R��I,D,
Property Owner: ) F y t -N m r )1. I'TVd& Zip Code: %�)._ I
-LfOwner Address: _f.. R� e5 City:
State: CA Zip Code: Home Phone: q 1 1' — 17 '3 I a
Owner's Authorized Agent: Work Phone:
Agent Address: TWO' ...1.. Z l..fNll� 1 v r" i- .�,�) S City: I 'D6PVr i, p
State: ' Zip Code:F14 Agent Email Address:
Escrow Company: Ilk ..._._-..c.v..-_0.......a-1�M ...... ........ ... � EscroW#MM 1 I
Escrow Address. city: Da3.1 I _eh _� - A YI-�(_ u,� _.. _- A e
State: C Zip Code _ ) is row Phone �O—
Email Report to:
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For Inspection call (Name): S C (O{� ���.� (, {� Direct Phone:
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELOW)
I authorize inspections and re -inspections ofthe property listed above. I understand that if Building orZoning
violations are discovered I will be responsible to correct said violations.
Owner/Agent's signature to authorize Inspection:
Sign here t'o,decline
Owner/Agents signature to decline Inspection:
Date:
OR
Caec481 n,dby; Date: r
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Account # 01050504-5210401.............—Make checks payable to: CITY OF NEWPORT BEACH
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