HomeMy WebLinkAboutR2023-0325 - Permit ApplicationPrint Form City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT RECEIVED
BY
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BUILDING DIVISION DEOMMU COMMUNITY
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100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-8915
RB�F 22o Z3 - 0�2-5 www.newportbeachca.gov 1 (949) 644-3200 APR 212021
Application for Report of Residential Building Records CITY OF
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Application Fee: - $202.00 Notice:
(For All Residential Buildings) Applications with insufficient fee payment
Reinspection Fee $134.00 or incomplete will be returned
Please type or print and complete all information
# of Units: Address: a�o� Ste' S� . # 9 City: Newport Beach State: CA zip: %//zv3
PropertyOwner: � nP /� se2& Z— Zip Code: 7 3
Owner Address: .2101E Sf v 9City: /P�, v1�ff"i3���j,
State: CA _
Zip Code: zw 3 Home Phone: 9y9 .Nr ,� 7
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Owner's Authorized Agent: mal//. 1 , !� Work Phone:
Agent Address: ! ��d /Q�P11CrT/tii �(/ e City: SAS
State: Zip Zip Code: 2� Agent Email Address: r'►1 a,-C e/ice c5/c�n�P j .
Escrow Company: / I-v i x a ( /�klP U&rQyI I/ Escrow #: 203
Escrow Address: 130D 10bzle �/f 3i-G{ —/�i�' City: 1/ e, cl O, -t /3e4
State: Zip Code: ����� Escrow Phone: t/
Email Report to: naC Y; h enoo daO
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�rr OR
Owner/Agent'ssignatureto decline "lei l' • /" Date:
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
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