HomeMy WebLinkAboutR2023-0190 - PermitsPrint Form
City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
RECEIVED BY
COMMUNITY
DEVELOPMENT
MAR 0 8 2023
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 1768 Newport Beach, CA92658-8915 CITY Ot
RIllIF# 92OZ3 � O \C1ci www.newportbeachca.gov (949) 644-3200
IVEWPORT BEACH
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
C
Please type or print and complete all information
2 (� y: p State: A izip:
# of Units: Address: City: New ort Beach C
Property Owner: Zip Code:
I
Owner Address: ��� C' City: 1 ` ,
State: CA Zip Code: Home Phone: J
Owner's Authorized Agent: Work Phone:
Agent Address: City:
State: Zip Code: L� Agent Email Address:
Escrow Company: ,�\`j j / j Escrow #: 0 j-�3-72Y—(57 k-,�
Escrow Address: �Z�L Q9� City:--
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State: ? _. Zip Code: (u V) Escrow Phone: ?Ltm,/Y . 75/
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 responsible to correct said violations.
Owner/Agent's signature to authorize inspection:
Date:
q: ®_
Owner/Agent's signature to decline Date: 51 I
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
B u i I d in g_ D i v i s i o n\ F o r m s\ R B R_6-15-2 2