HomeMy WebLinkAboutR2023-0358 - Permit ApplicationPrint Form City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-8915
ROW (C202 $ ' O 358 www.newportbeachca.gov 1 (949) 644-3200
Application for Report of Residential Building Records
RECEIVED BY
COMMUNITY
DEVELOPMENT
APR 2$2023
CITY OF
NEWPORT BEACH
Application Fee: - $202.00 Notice:
(For AIIResidential Buildings) Applications with insufficient fee payment
Reinspection Fee $134.00 or incomplete will be returned
Please tvpe or print and complete all information
# of Units: ro Address: I'Gd t 1 � h� � I 1 City: Newport Beach State: CA Zip:
PropertyOwner. JG[aaA�p�I�j(�� Zip Code: al�Gd
Owner Address: 1100}l��lU 1I City:
State: CA Zip Code: G(96 1 /Home Phone:
Owner's Authorized Agent: Wig q/ Work Phone: q' S 5f-1i(40
Agent Address: i �Q'(� R�1 City:
State: Zip Code: % 14 Agent Email Address:
Escrow Company: ( 41l; L-s6(6%j Escrow #: � %
Escrow Address: '�JIlO All6q olliku ill City' �1 `l%,A 01Ll
Stater A- Zip Code: gaCga Escrow Phone:
Email Report to: �y9 ► ®Nwlkre�l�t(�'ca� DPIMGlur l�l •(6
For Inspection call (Name): J� { Direct Phone: L�q-Sso—yvDa
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:
Owner/Agent's signature to decline
OR
Date:
Date: a r a
Building Dlvlsmn\Forms\R3R 5-Is-22
Account # 01050504-521040 ..................Make checks payable to: CITY OF NEWPORT BEACH