HomeMy WebLinkAboutR2021-0264 - Permit ApplicationREC��prO
Print For City of Newport Beach cOn�"'LrojTre`
COMMUNITY DEVELOPMENT DEPARTMENT qP�
BUILDING DIVISION
�f 100 Civic Center Drive I P.O. Box 17681 Newport Beach, CA92658-&1*1'F,O
RBR# tt �Zf L� % www.newportbeachca.gov (949) 644-3200
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Application for Report of Residential Building Records �IV"ORT WIc<
Application Fee: - $194.00 Notice:
(For All Residential 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: �j Address: 60 )09-1 Gy*-'\�/\\t4• I)4• City: Newport Beach State: CA _jjZip: 9a66�
Property Ownerf N24 J RR.tv,Rr-,..,. I Zip Code:
Owner Address: 10 ?L Gro>1vM2.__.Cjf. City: NewpOf QRU(I,
State: CA _, - Zip Code `1a6b 6 Home Phone _..I
i
Owner's Authorized Agent: Work Phone:
Agent Address:', City:
..................
State: F Zip Code: Agent Email Address:
Escrow Company: ESCfO.w_.. Escrow #. Q S y S a�
Escrow Address: 12,(lJ tJ¢wp W CR.r'1'2 t Dv - -33 j� ,.... City: NQ.t-vvo qlQ6\a•L
State: Zip Code: °h.66Q Escrow Phone: 949. 64y•.3013°`
Email Report to:
For 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. I understand that if Building or Zoning
violations are discovered I will be responsible to correct said violations.
Owner/Agent's signature to authorize inspection:
OR
Owner/Agent's signature to decline inspection:
Date:
Date:. N.- / I -dOeC.a.__.
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
Building Division\Farms\RBR_)-30-20