HomeMy WebLinkAboutR2020-0965 - Permit ApplicationCity of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
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vc Center Drive I P.O. Box 1768 I Newport Beach, CA92fi58-89�
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Application for Report of Residential Building Recordks°PUF,t ,
Anphdatibn Fee $: Iq Notice:,3: pw .
(For All9tesidenttal Buildings)' Appltionswith insuffic6ent ee
icapayment:
Reinspection or incornplete will - Be: returned'
Please type or print and complete all information
# of Units: i 17 Address: L.I Z,2j City; Newport Beach State: aZp: p 206
Property Owner] i EKaV 1
Zip Code:. �jiCQ
Owner Address:
State: ZIP Code: — l��lX Home Phone: 6I L 1 • ,-LC) . C U Z C
Owner's Authorized Agent:a "A� � Work Phone: awq :t(lu .
Agent )'Addrress: ' �N� ` ,1, S`{/w I City' q
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State: � Zip Code: ® Agent Email Address: Q� U4 • C.C.tI�:
Email Report to;
For inspection call (Name): Direct Phone:
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELOW)
I°authorize inspections.and.re=inspections ofthe property risted above. I understand,that.if Bu.ildingorloning.
violations are. discovered'[ will be: respnnsibi'eto correctsa:id viiolations.
Owner/Agentssignature to authonlie inspection,
Owner/Agent'ssignaturetD decline. inspection:
HWltling_Oi.¢i.n\Forms\886 9-18-16
Date:.)
OR
Account # 01050504-521040— .............. Make checks payable to: C17Y OF NEWPORT BEACH