HomeMy WebLinkAboutR2023-0294 - Permit ApplicationCity of Newport Beach COMMUNIY TT'
COMMUNITY DEVELOPMENT DEPARTMENT DEVELOPMENT
BUILDING DIVISION APR 12 Z023
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-8915
MM iZZOZ3 ^ OZo1 y www.newportbeachca.gov 1 (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 $134.00 or incomplete will be returned
Please tvoe or Drint and complete all information
#ofUnits: Address: City: Newport Beach State: CA Zip: q'Z�
Propertyowner: we— S (, LC - �+I 59 &Yi3 Glt O(41 Zip Code:
Owner Address: City:
State: CA Zip Code: , Home Phone: W, ILI^ ' �_ 3 5- 7U `7
Owner's Authorized Agent: Work Phone:
Agent Address: City:
State: Zip Code: Agent Email Address:
Escrow Company: Escrow
Escrow Address: 1Zda Al -ri� �� City: a/
State:i Zip Code: ® Escrow Phone:
r,
Email Report to:
For Inspection ca
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
Owner/Agent's signature to decline e: �_
Account # 01050504-521040 ...............
Buildi, Divi1ion\Forms\XBR&15-22
payable to: CITY OF NEWPORT BEACH