HomeMy WebLinkAboutR2023-0820 - Permit ApplicationDocuSign Envelope ID: 65264530-DA2F4E17-A66C-05751FDC9002
Print For City of Newport Beach RECEIVED By
COMMUNITY DEVELOPMENT DEPARTMENT DEVELOPMENT
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA926584050 g 2023
RBR# RZa,11' 02 IL www.newportbeachca.gov 1 (949) 644-3200
CITY OF
Application for Report of Keslaenraal tsuuaing Kecoras --ml ijFAcH
Application Fee: - $208.00 Notice:
(For All Residential Buildings) Applications with insufficient fee payment
Reinspection Fee $138.00 or incomplete will be returned
Please tvoe or print and complete all information
It of Units: F—j Address: 1f$2/ ar-Mcnol /h;wI City: Newport Beach State: [CA !Zip: y2{o is -
Property Owner: rla►� VAhVIV(, �ytyt¢t� V4tS( Zip Code: Gl�621�
Owner Address: t I - City:
State: CA Zip Code: F— Home Phone:
Owner's Authorized Agent: MO q �b I y) V"t t 1 l I (,gym Work Phone: �10 3 l e- r y 12
Agent Address: �()� AA AW,03 City: _(JfN�'l,p, &Cack,-C14
State: C� Zip Code: To7-(01 Agent Email Address: hna�ly
Escrow Company: I G vXV-W � �- V 00 �(, Escrow #: 23- 206�2�-7- 36
Escrow Address: 2(00 �(^(1�jL �a�� b� l city: %(/(/j olo, 6,,a7
State:FX
Zip Code: ��� Escrow Phone:
Email Report to: l jumi -V-. ( r-e �. j I" '���/�/ -
For Inspection call (Name):I"�JJp ettV\V;•jjk.WT 5 _ J Direct Phone: �f�D 3I I1I2-
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.
DocuSignedby: /III111I
Owner/Agent's signature to authorize inspectiEIMABDA[16ME441
tb(4i N-biy, Wtuiawils Date: 9/6/2023
_.
OR
Owner/Agent's signature to decline
Date:
e end ing_Drvc:,n\Fom5\Nb R_6-15-22
Account 4 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH