HomeMy WebLinkAboutR2021-0271 - Permit Application (2)DocuSign Envelope ID: 09DF3053-5FCE-4002-9959-FD81 OB9351 FB Cpl SJJ ��
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COMMUNITY DEVELOPMENT DEPARTMENT C) 'ptCp
BUILDING DIVISION < 0'42F40
12 / t n o '/ 100 Civic Center Drive I P.O. Box 17681 Newport Beach, CA9265�p15 �` ov,T
RBR4 Z i www.newportbeachea.gov 1 (949) 644-3200 SHORT BEPG�
Application for Report of Residential Building Records
Application Fee: - $194.00 Notice:
(Fpr All Residential Buildings) Applications with insufficient fee payment
Reinspection Fee $129.00 or incomplete will de returned
Please type or print and complete all information
#ofUnits: Address; City; Newport Beach State: CA]Zip; !
2660 l
Property Owneri .._..w...Ann._.5..-..Mackan.z-ie,_..T___.__._.---...,..._._._.._...____.! Zip Code:
Owner Address: _ 19161 Si_erra_Maria Road City: Irvine_
State: CA -Zip Code: 92603 Home Phone; 49 677 9282..
Owner's Authorized Agent: UAPt6_k11115iIiSQt1 _ ^� Work Phone:
Agent Address:
..._._._._5.2.99__alt..an._P..arkway__.. _..__-.___...� city:
State: Ca_� — Zip Code: 82660 Agent Email Address:
Escrow Company: _ 1._—_._0.04�3_8Escrow #: N2
Escrow Address: I Cit
y'
State:�u Zi Code:
CA p 9266D i Escrow Phone;, 94,9,_945 2914v�__
Email Report to;
For Inspection call (Name): — y µ _ 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'ssignaturetoauthorize Inspection:;/ Ja�;ew:lk.« Date:
FaeAeAa&Po Fe._
Owner/Agent's signature to decline inspection:
8Ul1d1ngyM11M\F0=vt6H ]•3020
Date: r�
Account # 01050504-521040 .................Make checks payable to: OTYOFNEWPORT BEACH