HomeMy WebLinkAboutR2023-0367 - Permit ApplicationPrint Form City of Newport Beach RECEIVED BY
COMMUNITY
DEVELOPMENT
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION MAY 022023
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-8915
mf %42 V-5 03'(0-7 www.newportbeachca.gov 1 (949) 644-3200 CITY OF
NEWPORT BEACH
Application for Report of Residential Building Records
Application Fee: - $202.00 Notice:
(For Ali Residential Buildings) Applications with insufficient fee payment
Reinspection Fee $134.00 or incomplete will be returned
Please type or print and complete all information
#of Units: Address: �}-Iq C gAY AvL, City: Newport Beach State: CA Zip: ct7-66
>/: TOM i- JAEN4 I M$O,D��.l A,A *j PUU45r 1
Property Owner. I0gI PUW51L11 IL012-1 PULASK-1� Zip code:F-
Owner Address: I IOZ(o N1 106-Ti+ 5T City: LINCOL-N
State: a N lar Zip Code: (o QI Fj Z� Home Phone: -rom : 1 14- - �5 q.5 - 3q 4-1
Owner's Authorized Agent: ICYNTHiA Work Phone: IA- - %3T- 6111LI
Agent Address: 3 01-1 (✓ P UTF+ P L City: C)Q a, I.1 ti1�
State: C'A; Zip Code: q7-- ®l Agent Email Address: Cindy.0Ct-e4y41100. Cot"
Escrow Company: I L 5CTZA W OAT I Oril S
Escrow #: I ik 3- 5 0 4,18 - S 7
Escrow Address:11¢OD iQ N4R-zoP-- 61_VDy-110 City:I IPLJLL~:R-Ta►�A
State: CA Zip Code: Fq Z8 3 s Escrow Phone:
Email Report to: 15A. RA'c J I IM>✓ N C Z
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:
OR i/�
Owner/Agent's signature to decline Date: Yj JZ�ZOZ?j
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
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