HomeMy WebLinkAboutR2021-0179 - Permit ApplicationPdnt` Fora, City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-8915
RBR# V www.newportbeachca.gov 1 (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
F
4 of Units:
Newport ort BeaA !Zip: -��15
Address: j State: F 1, al)S-A� 0,51"A� 6111City: 1 - . 1. 1 ---
Property Owner:1. 1 Zip Code:
1 1 -
Owner Address: City:
State: F Zip Code: 1 Home Phone: I
Owner's Authorized Agent:alsJ _, Work Phone:
Agent Address: city:
State: FT Zip Code: FZ74b Agent Email Address:
Escrow Company: Escrow #:
Escrow Address: City:
. .... . ........ .... .
Zip Code: Escrow Phone:
Zw— -u�
State: F (C-1)
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: Date:
(
jOR CIP
JI
owner/Agent's signature to decline inspection: Date: '3
Account # 01050504-521040 .................Make checks Dovable to.- CITY OF NEWPORT BEACH
Bu11d1ng_Q1vis1nn\Forms\RBR 7-30-20