HomeMy WebLinkAboutR2021-0262 - Permit ApplicationPrint Form City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT ^fY
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-99151' "02'
RBR# LVG ULIN www.newportbeachca.gov 1 (949) 644-3200
Application for Report of Residential Building Recordik�,,,.,
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: Fsz'" Address: Y3 Anj0L City: Newport Beach', State: CA Zip: q5 5-1
Property Owner: -rile (-,f SGl 6
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Owner Address: T 3 IO �l _ City: .e /Crt I_. e-
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State: CA / Zip Code: `7a(;5 Home Phone: F41,,57- l.0
Owner's Authorized Agent: JAS if-
Agent Address: tnFi.,l-�O.NoCity:
State:F5 v Ti �1ZOip Code:q2l ij-(o rr4CAgent Email Address:
Work Phone: I 3.10'. 801 - _S1 I 1_..
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Escrow Company: CX S+ Al ()-fe_ Se t/ eyy�t Se( -Y )Ces Escrow #: FL
Escrow Address: ��%(� fll�(a or�!-_i\_.n-1._r. ..� .fie;, city:
State:�'r " Zip Code: q 1.���.e.V Escrow Phone:
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Email Report to:
For Inspection call (Name)
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J41()-t(V Aug4;n Direct Phone: 310-' N,!p 19
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 authorizeinspectio Q
OR
Owner/Agent's signature to decline inspection:
Building Division\Forms\RBR_7-30-20
Date: 7,
Date:
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH