HomeMy WebLinkAboutR2021-0805 - Permit ApplicationCity of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
VOI/(—O(L OG 100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-8915
1 V "�(// ��✓✓ www.newportbeachca.gov 1 (949) 644-3200
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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
#of Units: �, Address: �� , City: Newport Beach State: CA 'Zip:F
Property
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Owner Address: �
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State: CA _,. Zip Code: _,
Owner's Authorized Agent: I C o Work Phone: �L4fiT / 'V O i
Agent Address: L 1 J D W. UCC" City:
State: F Zip Code: RWV
Agent Email Address:
Escrow Company:_�—'
Escrow Address: y -
I l ^� I I" " /City:
State: �— Zip Code: ' " I ✓ \ 1
Email Report to:
For Inspection ca
Escrow #: 1,12/1 -
Escrow
„ 1
Escrow
I
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:
Owner/Agent's signature to decline inspection:K
— lsCy� Date:%-
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORTBEACH
B.ildin,Divi.i.n\Forms\NBP_7-1-21