HomeMy WebLinkAboutR2023-0449 - Permit ApplicationPr;nt Form City of Newport Beach RECEIVED BY
COMMUNITY
COMMUNITY DEVELOPMENT DEPARTMENT DEVELOPMENT
BUILDING DIVISION n�yy 92023
100 Civic Center Drive I P.O. Box 1768 Newport Beach, CA9265,0 919
RSR# (LZo Z 3 O �H� www.newportbeachca.gov (949) 644-3200 CITY OF
NEWPORT BEACH
Application for Report of Residential Building Records
Application Fee: - $202.00 Notice:
(For All Residential Buildings) Applications with insufficient fee payment
Reinspection Fee 5134.00 or incomplete will be returned
Please type or print and complete all information
# of Units: Address: a l -7 I � 1-n. � V C Y W n 0 City: Newport Beach State: CA Zip: a (0(0O
Property Owner. Tq G aonnon Ek-C N
Zip Code: F
Owner Address: I o I n OV r (mil ) City: . N VO YT Pa ci l
State: CA Zip Code: R70b O Home Phone: I
Owner's Authorized Agent: � y i v ccnv _ Work Phone: r �y 4 q c%-�, q / 06
Agent Address: 5 3Vft V cF+--^ *ci City: l V l; VU "- & 6-0 u' f
State:' Zip Code: -la 0W 3 Agent Email Address:
Escrow Company: tV vV V V V Escrow #:... w -vo 47 o —u<
Escrow Address: 5 60+P1 -�, .#a City: N W pV r l KoI
acl
State: i Zip Code: �0 Escrow Phone: L 0,2 � V/✓T-
Email Report to:
For Inspection call (Name): I k
W. �tql
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 correctsaid violations.
Owner/Agent's signature to authorize inspection: Date:
r OR
v
Owner/Agent'ssignatureto decline `�a� C�5
Date:1
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
8uiltling Division\Forms\RBR_6-15-22