HomeMy WebLinkAboutR2022-0158 - Permit ApplicationPnnt.Form" City of Newport Beach COMMUNITY
COMMUNITY DEVELOPMENT DEPARTMENT DEVELOPMENT
BUILDING DIVISION (�kp `� 2oZ2
100 Civic Center Drive I P.O. Box 1768 Newport Beach, CA9265
RBRiI�Z� www.newportbeachca.gov i (949) 644-3200
CITY OF
ication for Report of Residential Building Re
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 inforniBt,.lon
N of Units,'� � ��
Address:
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State: CA Zi
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New ort Beach
Property Owner: Zip Code:'
-_ 7W_0,c�r- .
Owner Address. `-:-.-1r---(� l.i_`ex. :. City:
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State: CA Zip Code; 1�� Home
Owner's Authorized Agent: "`}j� 5-40 Work Phone.
Agent Address;,1 t..%1.:� ✓..1S,r.:-_S.J:__.i City:]: —
State: i f Zip Code: 5� Agent Email Address�l
Escrow Company: J( /j _�� Y ."1 '_.�) Escrow tl• «J_ ) '� ( y 4
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Escrow Address City:
State: 1 \ 1}i-1- Zip Code Escrow Phone:t, ;.
Email Report to;
For Inspection call (Name): Direct Phone:
:CONSENT TO INSPECT (FORM MUST 13E S1CsNEDA DATED BECO.Vu)'�
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
/t�said
�violations.
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Owner/Agent's sign aturetoauthorizeinspection:.. _ lJ 4ZC--1r-%.. Dater
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OR INIC-0 3/23/2022
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Owner/Agent's v nature to decline inspection: ��a5MB9«sE<os F � 1
3/22/2022
Account tt 010SO504-521040 _.......... ..... Make checks payable to: CITY OF NEWPORT BEACH
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