HomeMy WebLinkAboutR2023-0946 - Permit Application (2)RECEIVED By
City of Newport Beach CEO PM NT
COMMUNITY
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION OCT 2 5 2023
n d 100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-8915
RBR# 202`� - 14fo www.newportbeachca.gov 1 (949) 644-3200 CITY OF
NEWPORTBEACH
Application for Report of Residential Building Records
Application Fee: - $208.00 Notice:
(For All Residential Buildings) Applications with insufficient fee payment
e on Fee $338.W ----- - --- —"— — - or incomplete will Tie retumEe
Please type or print and complete all information
# of Units: FT7 Address: 1500 Avenida Lorenzo City: Newport Beach State: CZIP: g2660
Property Owner: Survivor's Trust of the Anne and Don Clark Trust Zip Code:
Owner Address: City:
State: I Zip Code: Home Phone:
Owner's Authorized Agent: Work Phone:
Agent Address: City:
State: I Zip Code: Agent Email Address:
Escrow Company: Freedom Escrow I Escrow #: 056024-MM
Escrow Address: 1200 Newport Center Dr., Suite 180 City: Newport Beach
State: CA Zip Code: 92660 Escrow Phone: (949) 644-3939
Email Report to: mm@freedomescrow.com
For Inspection call (Name): N/A 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:
OR
Owner/Agent's signatureto decline ey /46N7— Date: /lj -2 S • 23 _
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
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