HomeMy WebLinkAboutR2021-0181 - Permit ApplicationDocuSign Envelope ID: 9EED92B9-A2C8-44CD-AAC1-52F59C7A3EB6
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City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-8915
www.newportbeachca.gov 1 (949) 6443200
Application for Report of Residential Building Records
Application Fee: - $194.00 Notice:
(For AIIResidential Buildings) Applications with insufficient fee payment
Reinspection Fee $129.00 or incomplete will be returned
Please type or print and complete all information
#ofUnits: F— Address: e60 6. 0CeQ /I City: Newport Beach State: FCA Zip: 9a2sa l
Propertyowner: r%)�Cqrfj- ;k Zip Code: F—
Owner Address: 1348 N Santiago St City; F
anta Ana
State: CA Zip Code: Fi7E Home Phone: 800-540-1859
Owners Authorized
/Agent: IOHV�jyryi/� �¢ �({�l� Work Phone: �—
Agent Address: ��32 61 ow"11441 abt . City:F-6--FOA
State:F� Zip Code: Agent Email Address:
Escrow Company: 60rneer 3Cre1.—j Escrow #:
Escrow Address: l V2 _TV-UI�A,I? ffIU4irVity, rj-t- 5 'n t u
State: FCA // /; Zip Code:: P7.9%d /l/ Escrow Phone:
46
Email Report to: rt @ Co Ir-n-er(f J Cy�%W 1 Lu
For Inspection call (Name): I 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 orZoning
violations are discovered I will be responsible to correctsaid violations.
Owner/Agent's signature to authorize inspection:
Date:
eusl nod by:
Owner/Agent's ent's signature to decline inspection: n' Date: K3/6/2021
Account # 01050504-521040 ................. Make checkspoyable to: e1TYOFNEWPORTBEACH
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