HomeMy WebLinkAboutR2023-0971 - Permit ApplicationPrint Form
RECEIVED BY
City of Newport Beach COMMUNITY
COMMUNITY DEVELOPMENT DEPARTMENT DEVELOPMENT
BUILDING DIVISION NOV 062023
100 Civic Center Drive I P.O. Box 1768 Newport Beach, CA92658-8915
RBR# Qri.023 b� www.newportbeachca.gov (949) 644-3200 CITY OF
NEWPORT BEACH
Application for Report of Residential Building Records
Application Fee: - $208.00 Notice:
(For All Residential Buildings) Applications with insufficient fee payment
Reinspection Fee $138.00 or incomplete will be returned
Please type or print and complete
all information
# of Units: Address:
30? A
I f -C� v-`
City: Newport Beach State:
CA
Zip: 92 or6 e
Property Owner: G�/af' rl"]Lfh✓(%( e>I- a( Zip Code: F
Owner Address: ��3 y,FC'o�,�l., Z/3 City: C®�,ft ��
State: CA Zip Code: 26 lime Phone:
,,ah
Owner's Authorized Agent: V,Ay� C7, f/ ,-. -14
Agent Address: I,TZ3y.4,'re, 'V� A::sl
State: Zip Code: iZb'Z-r
1)0 2/3
Work Phone: l /y7 . 7 2 2 •26%�
City: CsrMG 4A/ 11074 -
Agent Email Address: ot( ,-OIA /& �'FjQQQ�liA,7 & - ce,Jt
Escrow Company: /•-eCo�/� C,._� Escrow #: 0 5 6 d (4?- UW
Escrow Address: I'dU� I�Ct.v`� '(S v5'FY{-(•—I�6y: P,oVfCArl 1&061
State:I fir\ Zip Code: g'J-66b Escrow Phone: ly l 64'4 291
Email Report to: I -SW (2, rrte
For Inspection call (Name):
IV)QSGrbw -Cbrv�
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:
O
Owner/Agent's signatureto decline Date: �/ , 5. Z-
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
Building Divkion\Forms\RBN 6-15-22