HomeMy WebLinkAboutR2021-0611 - Permit ApplicationCity of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
/g ���I -0 �� 100 Civic Center Drive I P.O. Box 1768 1Newport Beach, CA 92658-8915
RBR# � 9�/ IJUI www.newportbeachca.gov 949) 644-3200
Application for Report of Residential Building Records
Application Fee: $198.00 Notice:
(For All Residential Buildings) Applications with insufficient fee payment
Reinspection Fee $131.00 or incomplete will be returned
Please type or print and complete all information
#ofUnits: I , I Address 11z JI a City: Newport Beach State: CA :Zip: L32w
PropertyOwner: M.� 6hael �QJI/1 S((��(� V"� _ _—.. Iq',, (gyp /IZipCode:
Owner Address: I I Z VI G1 iL lT F City: Ivl✓w -�� lJ( �{ I
State: CA Zip Code: piio 3 Home Phone:
Owner's Authorized Agent: Work Phone:
Agent Address: City:
State. F� Zip Code: F Agent Email Address:
_.__
Escrow Company:t'�(c Esccrrow#: &U((D202 NP
Escrow Address: 1.1(�ILlln (li City: Ci�nl_Qi�
State: —i Zip Code: �'yl,p'1 Escrow Phone: q) �-qmq
Email Report to:
For Inspection call (Name): Direct Phone:
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 correct said violations
Owner/Agent's signature to authorize inspection: Date:
OR /
Owner/Agent's signature to decline inspection:/ Date:r /
Account # 01050504-521040 .................Make checks payable to: C/N OF NEWPORT BEACH
Building Division\Farms\RBR_]-1-21