HomeMy WebLinkAboutR2020-0336 - Permit ApplicationDocuSign Envelope ID: B79BC629-92BO-43BC-A9EO-OC6A80BBDB77
City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
100 Civic Center Drive ( P.O. Box 1768 1 Newport Beach, CA92658-8915
RBRir•t%CA. 03 www.newportboachce.gov ( (949) 044-3200
Ann !cation Fee: - $191.00 motifs:
(For AIIResidentlatBuildings) Applications with insufficient fee payment
Reinspection Fee $129.00 or incomplete will be returned
Please type or Print and complete all Information
#of Units: Address: '� (� ...v'�.� - City: New;;; Beach, State: Zip:
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Property Owner:._ i^'}O.f'1 Ct ....: SS"?.�.1.4... .vlek- ... _....... j Zip[[Code: ( rpt:i.
Owner Address: 5..._�i 0.1 11 City' _..1`� E.t.,a Da n.t c b� ....... _'.
State: Iw" Zip Code q7( O ...__.. Home Phone:l 71 -.....L—I Oq
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Owner's Authorized Agent: Gy�,� .4 ,M1
Agent Address: 514 (.,}....-� � . coc,,sk Yll�
Work Phone: �`t5�...� J
City: •--tel a6.t`i9 [,}RGGt-t __...
State: I C4— Zip Code: ,-,j 2Q -t I Agent Email Address: ala 1�
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Escrow Company: ETC q -y /�^0 ,A L -5i �7!E -5u-O � .. . I. Escrow #: I� `P -CD C � I
Escrow Address: gj2v2 t—GbJ K.[] t�°�FJ �: L�A�UsI� J(Aett 1/
State: I . Zip Code: 112t,7 I Escrow Phone: 't' -1e1 _ u-zs —
Email Report to:
for Inspection call (Nainej:
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Direct Phone: F t
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'
coo.uftned by: nOR �DOeneJrned b"y:
F�"
' - -�4/_1.6/2020Owner/Agent's slgnaturetodecline inspection A9�0.
........
9288BE91661445C... 9268BE91601445C...
Account # D1050504-521040 ................. Make checks payable to: CITY OFNEWPORTBEACH
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