HomeMy WebLinkAboutR2019-1098 - Permit ApplicationDocuSign Envelope ID: 8E8DA446-9499-4F2C-BBA6-B08997FBE509
apfittf �I cYrn !"' ,cEtvea By
y �aruruNlTv City of Newport Beach
�iyryppMENT COMMUNITY DEVELOPMENT DEPARTMENT
o99nn��� BUILDING DIVISION
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] dO�wiC Center Drive I P.O. Box 1768 1 Newport Beach, CA 92658-89ly
RBR# CA % _ www.iiewporibea6hce.gov 1 (949) 644-3200
UIT`I OF �'
Applicatio&Rfor Report of Residential Building Records VV
Application Fee:. -$191.00
(For All Residential Buildings)
Reinspection Fee $129.00
9 of Units: F Address:
Owner Address:
Notice.•
Applications with insufficient fee payment
or incomplete will be returned
Pleasetype or print and completeall information
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Beach State: CA Zip:.
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... Zip Code:
City: �- u
State: CA Zip Code: Home Phone:
Owner's Authorized: Agent: •i, a� Work�Phoone; r-
Agent Address: �� ("��. -��gy' 1. (..,. ).
Stater-` ... Zip Code:Atgelnt Email Address: .,..
Escrow Company:
Escrow Address;
State: I L -rl Zip Code:
Email Report to:
For Inspection call (Name):.
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jA Escrow #: �s
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Escrow .Phone:y I'
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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:I
OR
p.cuSigl'111
ed by:
Owner/Agent's signature to decline inspection; � C��66� '1�,DaterC 516 IIASE4o3.
Account # 01050504-521040 .... ........ ..-Make checks payable to: CITY OF NEWPORT BEACH
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