HomeMy WebLinkAboutR2023-0371 - Permit ApplicationDocuSign Envelope ID: F03B14CC-B380-44ED-9C96-0O2AB5DE9956
Print Form City of Newport Beach I mmio�
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA926,5�Pgj%Z023
Rmw- 9,-LOL3 - 0311 www.newportheachca.gov 1 (949) 644-3200
CITY OF
Application for Report of Residential Building RecorA PORT BEACH
Application Fee: - $202.00 Notice:
(For All Residential Buildings) Applications with insufficient fee payment
Reinspection Fee $134.00 or incomplete will be returned
Please type or Print and complete all information
#of Units: F Address: 19Via Amanti City: Newport Beach state: ICA Zip: 92657
Propertyowner: Gayle and Andrew Polsky Zip Code:
Owner Address: 19 via Amanti City: Newport Coast
State: 1" Zip Code: 92657 Home Phone: 310-402-4960
Owner's Authorized Agent: Joseph Shmurak Work Phone: 949-678-1001
Agent Address: 28 SILVER CRESCENT city: FIRVINE
State: FcA Zip Code: 92603 Agent Email Address: Joseph@KeyHomeGroup.com
Escrow company: Ashley Bowman of Corner Escrow Escrow #: 10-14166-AB
Escrow Address: 18302 Irvine Blvd, Suite 350 city: Tustin
State: CA Zip Code: 92780 Escrow Phone: 714-922-3288
Email Report to: ashley.bowman@comerescrow.com
For Inspection call (Name): I Direct Phone:
CONSENTTO INSPECT (FORM MUST BE SIGNED & DATED BELOW)
I authorize inspections and re -inspections of the property listed above. I understand that if Building or Zoning
violations are discovered I will be responsible to correct said violations.
Owner/Agent's signature to authorize inspection:
OR
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D uftmd by: D.Cu$IgR by:
Owner/Agent's signature to decline ,�pinp ,q.lA, f��w P VJ p6u�
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Date:
Date: 5/3/2023
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Account # 010S0504-521040.................Make checks payable to: CITY OF NEWPORT BEACH