HomeMy WebLinkAboutR2021-0193 - Permit ApplicationPrint For City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
Ml—G0� 100 Civic Center Drive I P.O. Box 1768 Newport Beach, CA 92658-8915
RBR# www.newportbeachca.gov (949) 644-3200
Application for Report of Residential Building Records
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: F Address: I 4 (,c+'1 ( (,, ( • �, I. \j t \ -\ t. t.__l_., City: Newport Beach State: CA ..Zip:.
Property Owner �,)�-'1(�l\( v&Vii\ k�Ci 40)1�1'unA-- Zip Code: F--_-,.
Owner Address �( `r�:, i C`y-Y'c:' ��4r...<.._'. City:
State: CA Zip Code: Home Phone:
Owner's Authorized Agent 4r ( Work Phone:
` i 1.1 l \t � � _' �C� •0 1
Agent Address:`_) ��..�Il1alC �kl; i, City:
State: (`.)�'� Zip Code: �'� r.:b. l.. Agent Email Address:
Escrow Company: .k 4 v C1 v 1 l>v a t' t. ��� _.. Escrow #:
Escrow Address: I 1-:-)u- �`\.�k_'.... `�'t`�\",=r �,` lt1.t 1_� \ City: '..'i )J.. ...
State: Zip Code. <' Escrow Phone:
EmailReportto:
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 signatureto authorize inspection:
OR � (, D
Owner/Agent's signatureto decline inspection:
I
Date:
Account # 01050504-521040 ................. Make checks payable to: CITY OFNEWPORTBEACH
Building Division\Forms\NBP )3020