HomeMy WebLinkAboutR2020-0822 - Permit Application',OW1MUNl1Y
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City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENI SEP 2, 3 2020
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 17681 Newport Beach, rA92658-89115,
Re'Ra www.newpombeachra.gov 1 (949) 644-3206
'1� fVA10RT 60,0<\
Application for Report of Residential BuildinA Records
t%PlollcStlon Fee:.
:-SUW.00 It-ILI'
(For *11 Residential buildings) Notke:
Reintpettion I*# IZ$.Qo Applicatio is with Insufficient fee payment
or Incomp ete will be returned
Please —tYP9-or print and complete all Inforimati n
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N 01 Units: Address: �!m!.:h State:
city: F Bea, FA ]Zip:
Property Owner. - Zip Code:
Owner Address:
City:
State Zip Code; ���_�tv_�.�
Home Phone:
Owner's Authorized Agent: -CAWork Phone:
ms
Agent Address:
Zip Code:L.Agent Email Address: F7176—/ ,
Escrow Company: Escrow #:
Escrow Address; 1 31 3o- -&boT - 60a0k-Ta4city: F P-CpLT K -A-1
1[s
State: Zip Code: Escrow Ph c ne:RL7tqT-qTwj----
Email Report to:
For Inspection call (Name): DitectPhone:
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CONSENT TO INSPECT (FORM MUST BE SIGNED& DATE BELOWI
I authorize inspections and re -inspections of the property listed above. I understaniJ that If Building or Zoning
violations are discovered I will be responsible to correct said violations.
Owner/Agent's signature to authorize inspection: I Date:
OR
Owner/Agent's signature to decline inspection Date:
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Account # 01050504-521040 .................Make checks payable to: clTy OF