HomeMy WebLinkAboutR2021-0069 - Permit ApplicationDocuSign Envelope ID: BF7D309D-A20E4841-B6D5-8D38EDDCB8B8
Print Form, " City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
��jj qq q r 100 Civic Center Drive P.O. Box 1768 Newport Beach, CA 92658-8915
0069 www.newportbeachca.gov i (949) 644.3200
Application for Report of Residential Building Records
Application Fee, $194.13DNotice: -
(For:AllResidential Buildings) Application$ with Insufficient fee payment
Reinspection Fee $129.00 :` ` or Incomplete will be returned
Please ta or Print and complete all Information
itof Unitsr� Address: CA �l 6TD, iMZ }';.-City: Newport Beach: State: CA Zip; �2CotcJ'
ProPertY Owner. 6ttr�`F 1 � uuv Zip Code: a
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Owner Address: r- Ci f;
State: [CA Zip Cotler Home Phone:,'.3-`..�-^s-' 1
Owner's Authorised Agent: {v4Va_.. �„ tj r6 [ 1 Work Phone:
Agent Address: .r`. `r
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State:I t i(r Zip Code:2�! Agent Email Address::
Escrow Company:��t(`'//���I(( �,�z� ( / Escrow N: ]
Escrow Address: r — _ ��o�-C.. City: IG y`t
State: Zip Code: FqDU, pG,� yry pEscrow
�PPhone: �r�V
Email Reportto: //. _'y (. /�j�
For Inspection call(Name): G�(1J(Y GI ./A �. Direct Phone: 1.Qt 7- T1 `7'4L.4/ p
I authorize inspections and re -inspections of the property listed above. i understand that if Building orZoning
violations are discovered l will be responsible to correct said violations.
Owner/Agent's signature to authorize inspection:. Dater -
OR
-` c000sianm by
Owner/Agentssignature to decline inspection:' F�tle�A Fw1u Date: 1/28/2021 1 9:31
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Account 4 01050504-521040 ................. Make checks payable to: O"OFNEWPORr BEACH
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