HomeMy WebLinkAboutR2020-0316 - Permit ApplicationDocuSign Envelope ID: 0950DODA-639A-4DCA-B4C1-9E72ECEE9A8A
PRINT City of Newport Beach cl MMUNITY
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COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION j3,PR Q 0 2020
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100 Civic Center Drive P.O. Box 1768 Newport Beach, CA 92658-8915
RBR# R 2`0 20 0 31 �, www.newportbeachca.gov (949) 644-3200 CITY OF
Application for Report of Residential Building ROWds 0
Application Feer -$184.00 Notice:
(For all Residential Buildings) - - Applications withinsufficient fee payment
Reinspection Fee $125.00 or incomplete will be returned
Please type or print and complete all information
If of Units: Address: . �i y �t%-I\ S1- . _ Cit New -ort Beach State CA Zip:
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Property Owner. 11 is �Cl�'�(`('t��\`�_____. I Zip Code:I jet, C��'
Owner Address: City: 'V W/ ,'6:'7 13C�CIn
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State: CAi
Zip Code: - j�-i, b_j
Home Phone:
Owner's Authorized Agent:(A{r
Work Phone:
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Agent Address:
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State:
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Zip Code:
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Agent Email Address:
Escrow Company: ��;� �r; -e5C1 o Escrow#: 1--6) - 670 ( i
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Escrow Address: �. % 3) L IS e �rYe (_ l4- j-1 V City: r-)- 1
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State: _._ Zip Code: `4�b S6; Escrow Phone.
Email Report to: I.1JcI`!"( JGj e5Cl2cJ_C.Or�
For Inspection call (Name): , Direct Phone
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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 l will be responsible to correct said violations.
Owner/Agent's signatureto authorize inspection:
Owner/Agent's signature.to decline inspection:
OR
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569CDFI i M9450._
Date:
Date 4/1/2020 -
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Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
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