HomeMy WebLinkAboutR2022-0254 - Permit Application?rind Gm City of Newport Beach �CEIVEp eY
. OMMUNITY DEVELOPMENT DEPARTMENT COMMUNITY
BUILDING DIVISION DEVELOPMENT
pp ✓✓��' 100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-1494�5
RBR# F n2 7022J -1 _ www.newportbeachca.gov 1 (949) 644-3200 2 b ZI)22
Application for Report of Residential Building Records CITYOF
Application Fee: - $198.00 Notice: RT gEPG�
(For AIIResidential Buildings) Applications with insufficient fee payment
Reinspection Fee $131.00 or incomplete will be returned
Please type or print and complete all information
# of Units: I ` Address: / (, 114, NTc9n/
City: Newport Beach State: CA Zip: 4J�S7
Property Owner: / 1�/LI/J G. /0-14$/-( Zip Code: )L-Q-10
Owner Address: I / 2-cPo Q-e#/L, ST IUJC) City:
State: CA Zip Code: `t"�WO
Home Phone: c� 6Gc?,� Un7
Owner's Authorized Agent: �/�/C G�¢�J,J� /Z61 Work Phone: I --,? i cL
Agent Address: 71 1 GYJ S J fIl✓t/ i+Y� City: CC-40V;4 - L
State: G 4 Zip Code: Agent Email Address: e iEw�P w �1n
Escrow Company: I 6-1eA/t 7'b �SC-RD L✓
Escrow #:1 7—/ ,'
Escrow Address: L/ S-L N�4/POfZT cc c/ j /1� (t00 City: / %
State: Zip Code: -7"}.66o Escrow Phone: I `j o-g( _ .S-S- L- _pcl,s 3
Email Report to: Jjoa-l- lferL �/`aA'7 e(2SC1"f�4%, Cr7CY1
For Inspection call (Name): 69 Direct Phone: 7/V-: 6r76 o t 2-.
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 authoAW 5Pee9-QT1ON Date:
DECLINED
OR
Owner/Agent's signature to declineinspectionZ" yzy/�/j�L Date: S//9/2-
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
Building--Division\Forms\RBR_J-1-21