HomeMy WebLinkAboutR2020-0532 - Permit Applicationwrint Form. City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 92658-8915
RBR# V 5,3 v www.newportbeachca.gov 1 (949) 644-3200
Application for Report of Residential Building Records
Application Fee: - $191.00 Notice:
(For All Residential Buildings) Applications with insufficlent fee payment
Reinspection Fee $129.00 or Incomplete will be returned
Please type or Print and complete all information
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#of Units. Fi , Address. 201IX St. City: [N State: ZIP:F9 port Beach , F
OwnerAddress:
State: ICA Zip Code:1 Cau`(O
ZipCode:
I : F
City:Z�—
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Home Phone: JIA4� RD -"J ADV -v
Owner's Authorized Agent: Work Phone: ICS 3L41 LA
Agent Address: HSU N zwyAbu city: F-5�W k)XukcAq
Agent Email Address:
State: Zip Code;
FcA
Escrow Company: Escrow #:
F0
Escrow Address: [qJ;D Nb4ol city: INUVVoIrt -Un
State: Zip Code: Escrow Phone:
F Zip K 6 0 �'\ 19 4-q, 10
Email Report to:
For Inspection ca
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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 I will be responsibleto correct said violations.
Owner/Agent's signatureto authorize inspection: Date:
OR
Owner/Agent's signature to decline Inspection:�Date;
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
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