HomeMy WebLinkAboutR2020-0945 - Permit ApplicationCity of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT �� \
BUILDING DIVISION
1 n Civic Center Drive I P O Box 1768 Ne orl Bc
ea h 'CA 92658-5915
P� KI-01—KI-01—� A
www.newportbeachca.gov 1 (949) 644-3200
3lication for Report of Residential Building Records
Aooiication Fee: - $ " 154. 00 Notice: ..
(For AllResidentlal 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: M Address: 27'a //Y7da4 --� City; Newport Beach State. CA Zip:. . ZEE
ropertyOwner. Zip Code:
)weer Address: ozolLy &Loe, City: l flL�l>
tate: Zip Code: Home Phone: e Jtx) - Z3 9
)wner's Authorized Agent: � ��% 7a h Work Phone:
gentAddress; /r%�% 7�y�i�.y-L-t'i��1`-� City: A)
tate: Zip Code: Agent Email Address:
scrowCompany; �� Bf--Gf ./�''ClQ aX% Escrow#:i 46 o &// -- --5'
.scrowAddress: (j �c j i ? G?�P� � DCity: EiJ U '�fEaC j
;tate:Zip Code: y�.4,�slJ Escrow Phone:
.mail Report -to: 1 /ef) 7_, ,r:Z± 0.0%12
=or inspection call (Name): Direct Phone:
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELOW):
I authorize inspections,and re -inspections of the property listed above, l understand that if Building or Zoning '
violations are discovered 1 will be responsible to correct said violations;
Owner/Agent's signature to authorize i nspection.: Date;
OR
Owner/Agent'ssignaturetodecline inspection: Date: > o Z6J
Account # 010505041-521040_ ............... Make checks payable to:: CITY OF NEWPORT BEACH
�NdFLDW�Ien\FamnUtlR: ¢t&18