HomeMy WebLinkAboutR2022-0099 - Permit ApplicationPrint �ocm"
City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMEN
T
BUILDING DIVISION
�I/V —0011 100 Civic Center Drive i P.O. Box 1768 1 Newport Beach,
RBR# l www.newportbeachca.gov 1 (949) 644-3200
CA92658-891
Application Tor Report of Residential Building Records i V
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: F, Address: City: -117 Q zCity: Newport Beach State: Zip: z&&U
.....-�.-- �J L �t
PropertyOwner] % /%'j/f b( Jjjt? j
Owner Address: j v494Y l i (J/CtS�G�/��
State: CA 1i Zip Code: r�V
Owner's Authorized Agent:
Agent Address:
State: 31.
Zip Code:
City:
Home Phone:
Work Phone: 1.
City: Dal_._ _-
Escrow Company: - Escrow #: 73 / L J
Escrow Address:i'
�-I r_ - _ ..ane/e�, . �_ ... N 9 ._
State: I \ Zip Code: r�CJ( of �, ^ Escrow Phone:IWO T g /�g G
6
Email Report to: V �l-R� rv-rl I .l ,/'� ,�„
For Inspection call (Name): l r Direct Phone:
I T
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELOW)
I authorize inspections and re -inspections ofthe property listed above. I understand that if Building or Zoning
violations are discovered I will be responsible to correctsaid violations.
Owner/Agent's signature to authorize inspection: Date:
OR
Owner/Agent's signature to decline inspection: �G� �y Date: 02 / 26� /2022
Account # 01050504-521040 .............)..Make checks payable to: CITU OF NEWPORT BEACH
BuilMnt oivision�forms�IBR ]-1-21