HomeMy WebLinkAboutR2021-0165 - Permit ApplicationPrint Form City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
Q I� BUILDING DIVISION
y) ho AI V pt 100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92668.8915
RBRO OL YV www.newportboachon.gov 1(9491 Rdd•3�Oa
Application for Report of Residential Building Records
Application Fee: -$194.00Notice:
(For All Residential Buildings) Applications with Insufficient fee payment
Reinspection Fee $129.00 or Incomplete will be returned
Please type or print and complete all information
O of Units:I TM Address: New
f ` Q,� a z City: por[Beech Stale: ICA Zlp:F
Property Owner; I I-1..� �u-C�I� u Zip Code:l�`�
Owner Address: ��._...... �� City;
State; CA Zip Code: I__-_.._. Home Phone; r
Owner's Authorized Agent:_IVork Phone:`�,1^��-1
Agent Address; City:l^�
State: Zip Code:r Agent Email Address:
Escrow Company; �"LL;®�.a„ Escrow 0:
Escrow Addres5:.ithleen Brooks City:
State: TT Title Qpmpal i T - Escrow Phone; l�-~
15Q0 fl11all Sheat 3w III N �Bp&rb, CA 92660
Emall Report tq.1�q 289;3315 Phone 949-809-0617 Fax
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Far Inspection call (Name); Direct Phone:
CONSENTTO INSPECT WORM MUST BE SIGNED & DATED SELOWI
I authorize inspections and re -inspections of the property listed above. I understand that If Building or Zoning
violations are discovered I will be responsibieto correct said violations.
Owner/Agent's signature to authorize Inspection: Date: F—
OR
OR
Owner/Agent's signature to decline Inspection: L�-�Q AJhO ,(i �,.t}CJYlsonOat$;I`,--'aw •^d...�
Account 0 01050504521040 .................Make checkspayable to: CITY OF NEWPORT BEACH
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