HomeMy WebLinkAboutR2021-0469 - Permit Application�,�CEiVEt7 QY
COMMUNITY
Print Form City of Newport Beach DEVELOPMENT
COMMUNITY DEVELOPMENT DEPARTMENT JUN 2 4 2021
91ry BUILDING DIVISION
0 L `. 61 100 Civic Center Drive I P.O. Box 1768 Newport Beach, CA 92658-8915
RBR# www.newportbeachca.gov (949) 644-3200 CITY OF
Application for Report of Residential Building Rec IT elf
Application Fee: - $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:n Address: �3� P(>r.-t �( -fi`3�I��C-e City; Newport Beach State: CA Zip: q7(,,; LL
Property Owner: L�4.Y.S'r%il LSV I oTy v-,&+- _ _ Zip Code:
Owner Address: city:
State: CA Zip Code; Home Phone:
Owner's Authorized Agent: -t� bf�?i _
Agent Address: lC -e-��
Work Phone: C.{f=�
City: Kew u4be,)n
State: 0 Zip Code: q hiPci Agent Email Address: .p
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Escrow Company: �� 9�1 Escrow #:`—
Escrow Address: L'9 " CP Y\tx V k�v, I -a. City: �,t)frut'-{-
State: _f�'�' Zip Code: _ 3(.Q t>_r Escrow Phone:
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 I will be responsible to correct said violations.
Owner/Agent's signature to authorize inspection: Date: l -I
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Owner/Agent's signature to decline inspection: II`I u -n �A Ri ,v illy C. /h:l�r fi 11'?F�re1 .I I I
Account # 01050504.521040 .................Make checks payable to: CITY OF NEWPORT BEACH
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