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Print Form
City of Newport Beach
COMMUNITY D-EVELOPMENT DEPARTMENT
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-8915
RBR# ooc. %j www.newportbeachca.gov 1 (949) 644-3200
Application for Report of Residential Building Records
Application Fee: - $202.00 Notice:
(For All Residential Buildings) Applications with insufficient fee payment
Reinspection Fee $134.00 or incomplete will be returned
#ofUnits: 17 Address:
Property
Owner Address:
State: F77-7 - Zip Code:
Please type or print and complete all information
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Owner's Authorized Agent:
Agent Address: 1 -.-
City: Newport Beach
State: CA .,'Zip 7, �6 p6 3
Zip Code: � 45-6 6. 3
City: -Yew'0
Home Phone:
Work Phone:
City:
State: -� �.' Zip Code. %.l��ln -
P Agent Email Address:
Escrow Company: _ \ h� Escrow #: �' % 7(tS-
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Escrow Address: (p (� D �- �j I e� i CI ��� j City:
State: -C_I/� Zip Code ff�� Escrow Phone: qy 91-
Email Report to:
For Inspection call (Name): [., 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 or Zoning
violations are discovered I will be responsibleto correctsaid violations.
Owner/Agent's signature to authorize inspection: Date:.l
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Owner/Agent's signature to decline T�� ��-Lf/� Date:
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
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