HomeMy WebLinkAboutR2021-0059 - Permit ApplicationPrint Form City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
#99On O�c� 100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-8915
RBR# d.. J www.newportbeachca.gov 1 (949) 644-3200
onniirntion for Report of Residential Building Records
Application Feer- $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
#of Units; Address:�QJ! �`( ���Q(/% City: Newport Beach State: CA Zip: 9aG1-d3
Property Owner: � rL fm e 7-199- Zip Code: �,?GG.3
Owner Address:. ?05 va City:. /I/ywd,00/v�i1.2Ch
State: CA Zip Code:. 9aGG '� Home Phone:
Owner's Authorized Agent: FoamInvIn/n� n Work Phone: I 4114-�34(!
Agent Address: 9,10 Qgto }- C'lA�A
p A. x /0V City:
State:— Zip Code: .9966 Agent Email Address: 60fn117A
Escrow Company: ��� � .� F3�iJOZv Escrow #: tai a, ix
Escrow Address; L qQ NAd1V- 6AN city: 1Aqpa- &jeh, L,4
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Stater N I Zip Code: 9�Gdo Escrow Phone: glrlj- 169— Ow
Email Report to:l Sandi ye vp&w.,ml &A-q,,[a aou/r dow
For Inspection call (Name): ald, Direct Phone: f ---%
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELOW 1.
I authorize inspections and re -inspections ofthe property listed above. I understand that if Building orZoning
violations are discovered I will be responsible to correct said violations.
Owner/Agent's signature to authorize inspection: Date:
OR
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Owner/Agent's signature to decline inspection: �iy/rl,�,/ /�.� of"" Data:..../-4(� t 2472f
A --r a rnn9n5M-S7.1040.................Make checks payafle to: CITY OFNEWPORT BEACH
Building Dimsi0n\Forms\PBR_7-36 al)