HomeMy WebLinkAboutR2020-0281 - Permit ApplicationDocliSign.Enrelope ID: 0705E2D3-CD12-4011-9064-615509482FE1 ,i0elveb 9y
OOMMUNITY
PRINT City of Newport Beach f7EW�LtiM Nr
COMMUNITY DEVELOPMENT DEPARTMENT (NAR 11 ?020
BUILDING DIVISION
�/ 100 Civic Center Drive P.O. Box 1768 Newport Beach, CA92658-8915
RBR# \y7 Z W — 0 ZUC) f www.newportbeachca.gov 1 (949) 644-3200 CITY OF
Application for Report of Residential Building ReC&ftT BtaPo`
Application Fee: - $184.00 - - Notice:
(For. all Residential Buildings) - Applications with insufficient fee payment
Reinspection Fee $125.00 or incompletewill be returned
Please type or print and complete all information
- /1
#of Units: I Address: -Q
-
City: Ike�(n i'City: Newport Beach State. CA Zip:
7-(7
PropertyOwner. r5+c� k- Zip Code:3G6G
Owner Address: 1�6 tr L5h\\e earl !; City: '\i1tvi yr aced
State: CA } Zip Code ja.G 6 I Home Phone SbIf
Owner's Authorized Agent:
WAS+�ty
lni�l)lcJmS
�nrCp�; Sy
Agent Address:
Work Phone:
City:c w p ✓ f l� act
State: ! Zip Code: GG��'��� t0 5
4------ .' _t�""' V.,� Agent Email Address: ttje5f�e�� tJ\l ltan�J �hC.rCC r�5 �. rtOse-r
Escrow Company: (ns� ESa-o a%'. Escrow #
Escrow Address: a�3�Z-....� 1r5r3 CL�ii)_.._..... City: I
State: Zip Code ��-�,� �j ) Escrow Phone:
G.
Email Report to:l�ef Cl to --,e- A.(y l6 r—eSU'-w-,.6Om
For Inspection call (Name): I 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 signatureto authorize inspection: Date:l
OR
DDcu8ignea by
Owner/Agent's signatureto decline. inspection: - Date: 3/9/2020 -
-�-- sascDrinassaso._
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
Bull mll_DM.fan\`—\RRR.