HomeMy WebLinkAboutR2021-0472 - Permit ApplicationlilOf
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City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT ""yGVVED
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BUILDING DIVISION COMMUNITY
100 Civic Center Drive I P.O. Box 1768 Newport Beach, CA 926'6&-"V1
RBR# IC www.newportbeachca.gov I (949) 644-3200 JUN 2 5 Z021
Application for Report of Residential Building Records
Application Fee: - $194.00 Notice:
/IZUQYfic FiMrt f e e payment
(Fo r Al I Res identia I Buildings) Applications with
Reinspection Fee $129.00 or incomplete will be returned
Please type or print and complete all information
# of Units:F-Address: [ 4 *Vr-] Newport Beach State: F1Zip:FQ2& 0-K City:
-- — ----------- -------
Property Owner: [—��#-�AkTwooj -M05-r' Zip Code:
Owner Address: City:
State: FC7--7 Zip Code: Home Phone: I—q-k#�jw 0
Owner's Authorized Agent: Work Phone: I W10-30
Agent Address: I- ..j....--1._6.. -Pt�f- C]ly city: [N
I— -d-k-u
State :F—OF-7 Zip Code:
Fqy�406 Agent n
Email Address: [Aytvve4�A 0AWNk9X4L C,
Escrow Company:
Escrow #:
Escrow Address: City:
State: Zip Code:
lz5c-ov., Phone:
EmailReport to:
For Inspection call (Name): I 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: F
OR
Owner)gent's signature to decline inspection: V7 Date; jl lam(
Account # 01050504-521040 ...................Make checks payable to: CITY OF NEWPORT BEACH
Building -011W.n\F.,m,\RBR_7-30-20