HomeMy WebLinkAboutR2023-0293 - Permit ApplicationRECEIVED By
Prim Form City of Newport Beach COMMUNITY
COMMUNITY DEVELOPMENT DEPARTMENT DEVELOPMENT
BUILDING DIVISION APR 112023
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-8915
jMW iZ 2cZ3 - D ZCi5 www.newportbeachca.gov 1 (949) 644-3200 CITY OF
NEWpopT BEACH
Application for Report of Residential Building Records
Application Fee: - $202.00 Notice:
(For AIIResidential 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: LdS 3Y> City: Newport Beach''. State: 6�� Zip: &3
Property Owner: j,li,t'I
Zip Code:
Owner Address: `) ?j�'"'�� �.�..City: U
Stater; Zip Code: G1ZL(P,3 HomePhone:I
Owner's Authorized Agent:
Agent Address: _
Work Phone:
City' _ N e.u=[�-, 'ce.G4ti --
State:..----7..t}....-.---- Zip Code: F517k Agent Email Address:
Escrow Company: Escrow #: G"
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Escrow Address-. _j��Z'�4�- STL�.'°'E City: _'�(,LS..---------- ---
Stater—, Zip Code: qZ� Ck.l Escrow Phone: G
Email Report to: 52_YLLIt tiu�_%C {16 r 2 C r t_lA _ L 1 %�
For Inspection call (Name): Direct Phone:
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELOWI
I authorize inspections and re-i nspections of the property listed above. I understand that if Building or Zoning
violations are �, discovered Iwillberesponsible tocore iciviolations. /
Owner/Agent's signature to out � e inspection: y �d/! Date: V�(i% - /d - "L _-
/ \ OR
Owner/Agent'ssignatur0,todecliri - Dater
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
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