HomeMy WebLinkAboutR2021-0163 - Permit Application\aeCE.IVLI) 8Y
Print Forrifi' City of Newport Beach COMMUNITY
COMMUNITY DEVELOPMENT DEPARTMENT I)FVELOPMENT
BUILDING DIVISION MAR �pg 9
g 100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 97658=94�15
RBR# 0 1rI , - l b www.newportbeachca.gov 1 (949) 644-3200
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Application for Report of Residential Buildinjft or�.�
Application Fee: - $194.00 Notice:
(For All Residential Buildings) Applications with insufficient fee payment
Reinspection Fee $129.00 or incomplete will be returned
Please ripe or Print and complete all information
# of Units Address: & ®1� o w p /J F /a 0 City: Newport Beach State: Zip:64� j
PropertyOwner. VV�91�1I, C°, unCexI1iChT&
Zip Code: %6
Owner Address: ZP V o bw) Y" I n t, City:
State: CA Zip Code: �� Home Phone:
Ge -11
Owner's Authorized Agent: br mn C' I Cu I n i in Work Phone:
Agent Address: I II f CI (1i J V U 1. ICRC l l `1" Com: C"
State: CA Zip Code: 7A 6 7 3 Agent Email Address: b f` Unci l U( ISI11 \ CJ I. �,o fel
Escrow Company: IC`403� CA ES C r Q LQ a Escrow'#: , j
EsttowAddress: 635 eurni i,,o dt toCWLS City: j'all__ 1. -Cmelf1 tz
State: Zip Code: RlI Ip'l Escrow Phone:
Email Report to: �mn e—r- V OEUSC—(-Ol,0 , ( M
For Inspection call (Name): Direct Phone:
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELOINI
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: L?,;Z"3a
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
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