HomeMy WebLinkAboutR2020-0298 - Permit Application�UY.lVf:1S py.
Print Form City of Newport Beach CO MUNITY
COMMUNITY DEVELOPMENT DEPARTMENT DELoPMENT
BUILDING DIVISION kAR 13 2020
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, C 92658-8915
RBR# ` ,2 V • Alii www.newportbeachca.gov 1 (949) 644-3200
CITY OF
Application for Report of Residential Building R'ei;WAse,sO
Application Fee: - $191.00 Notice:
(For AIIResidential Buildings) Applications with insufficient fee payment
Reinspection Fee $129.00 or incomplete will be returned
Please type or print and complete all information
# of Units: SII Address l� `/\l (�[� City: Newport Beach State: CA. Ili Zip: �� 2��2
"1 W. I F _
Property Owner: U— 1viav Zip Code: F
Owner Address: City:
State:CA Zip Code: Home Phone:
Owner's Authorized Agent: N i� �II Work Phone:
Agent Address: City:
State:
�, Zip Code: �, Agent Email Address:li
Escrow Company: -. JL.VWv.__. _....
Escrow #: ��Sj�(_9�17�IIV J _
Escrow Address: �V'"_^I, n ;,rte' y.... i.' �Ity� �`�c�-I � J"I�' I
State: G t Zi Code:-Li,t.� V Escrow Phone:
Email Report to CQ -d om C-sC i!o/� - CL 1
For Inspection call (Name): I 6 v� 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:
Owner/Agent's signature to decline inspection: Date:
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
Building Division\Forme\RBR_9-18-18