HomeMy WebLinkAboutR2021-0180 - Permit ApplicationPrint Form City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 92658-8915
U/ www.newportbeachca.gov 1 (949)644-3200
Application for Report of Residential Building Records
Application Fee: - $194.00 Notice:
(For. All Residential Buildings) Applications with insufficient fee payment
Reinspection Fee $129.00 or incomplete will be returned
Please type or print and complete all information
#of Units: I �+" J Address: iv�--IL I I City: Newport Beach., State: CA )Zip. dtz 3,._..._.
Property Owner:-a�(-v_d.._{rrK.wL,r Zip Code:12(0._
Owner Address: [3U 4 0;N 4L'E I/v00P City: _. A (�l.f b_...__V -- -
State: CA _ - Zip Code: �i2cn� Home Phone 2A 4 -
Owner's Authorized Agent: IN
TTY C3dI 1�� ____._ __� Work Phone:
Agent Address: �` l 1 r,A/t City:
741�f--kLPAsF D.F I W(Ml l bi_s�VY
State:� Zip Code: 2 ' NTV � d_6N'G�S.r-ISI, U •_ (.
_I v�l � .__Z�f�j Agent Email Address:
Escrow Company:
._cogi �-_-QD(N-C ._.__.....------------_I Escrow #40----04_1-0.1-Z�._:ftiI
Escrow Address: Q430 _ N 6W ivl-
State: .GT\ Zip Code: Gi,�p J Escrow Phone:
Email Report to:
..VVtI--I—.—.._._._._ .._..
For Inspection call (Name): I-�1-` '�'G. R A, A F'1�7 Direct Phone: �� L
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 l will be responsible to cqrf ect said violations.
Owner/Agent's signature to authorize inspection:
OR
Owner/Agent's signature to decline inspection:
Date:
Date:
Account It 01050504-521040 ................. Make checks payable to: CITY OFNEWPORTBEACH
BAd1ng_D1vWon\Forms\RBR_7-30-20