HomeMy WebLinkAboutR2020-0334 - Permit ApplicationPrhit, Foim City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
'Q7n9n n'iAy�, 100 Civic Center Drive I P.p, Box17681 Newport Beach, CA 92658-8915
RBRIk {Llrw "� i!� www.newportbeachca.gov 1 (949) 644-3260
for Report of
Application Fee -$173.00
(For All Residential Buildings)
Reinspection Fee $117.00
Applications with Insufficient fee payment
or incomplete will be returned
Please tWpee or�print and complete all information
# of Units: F Address: i'i ' /® i� �/�/j C � State: I Z pf
Zip Code:_ I L2
Owner's Authorized
LlAgent: � ��_ Work Phone: q oo,(���r�
Agent Address; ' ]OD Q� City
State: I I f Vr Zip Cod
l: -V Agent Email Address
Escrow Company:
Escrow Address! F—
State: �—
Email Report To: I
For Inspection Call (Name):
City:
Zip Code: I`
Escrow #
Escrow Phone: I
Direct Phone:
CONSENT TO INSPECT (FORM MUST 99 SIGNED A DATED BELOWI
I authorize inspections and re -inspections of the property listed above. l understand that if Building or Zoning
violations are discovered I will be responsible to correct said violations.
Owner/Agent's signature to authorize inspection
O ner/Agent'ssi naturetodedine
Date:I
Date: ! zd/
Account # 2900-50115...., ::�.Makezheckg'payable to crry OF NEWPORT BEACH