HomeMy WebLinkAboutR2020-0949 - Permit ApplicationPrint Form City of Newport Beach jkCCEIvFU 19j -
COMMUNITY DEVELOPMENT DEPARTMENT `'OMMIUNI I
BUILDING DIVISION
7r, 100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA9g@�Bfil�
RBR# �'^� r:(-/ ^—�� www.newportbeachca.gov (949) 644-3200
Application for Report of Residential Building
Application Fee: - $19+.W iCtc{, 6 L
(For AIIResidential Buildings)
Reinspection Fee $129.00
Notice: ^�✓�?r7Hr t3EP0'�
Applications with insufficient fee payment
or incomplete will be returned
Please type or print and complete all information
# of Units:Lt� Address:( �iGir� City: Newport Beach State: CA Zip: G2'�
Property Owner] `,Q,Q, �� �, ir(AckiT1YtZip Code: F—
Owner Address: City:
State: CA Zip �ode: F Home Phone: I
Owner's Authorized Agent:
Agent Address:
State:
(6(MS
Zip Code: F
City:
Agent Email Address:
Work Phone: I OIL10i — U--75-- LA rT9,
Escrow Company: Escrow #:
Escrow Address: I L2.) IN W y) 6;v�, 00 City: I W 9jftt L,.VA I ,,
State: I lel Zip Code: �Zt,�CC.(] Escrow Phone: G�q��—l1G
Email Report to:
For Inspection call (Name): I nl
Direct Phone: OV
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:
OR
i
Owner/Agent's signature to decline inspection:
Date: I
Date: I i C( U3
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH