HomeMy WebLinkAboutR2021-0178 - Permit ApplicationCity of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
�I.1 100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-8915
RBR# 'f U www.newportbaschca.gov 1 (949) 644-3200
Application for Report of Residential Building Records
AppllFatibn Fees ti IC _I Noir , .
For.'AilBihsrderitia6Bylid[ngf)' ilppiicatibns:with.lhiufficfent•fee•paymentt
Rernspect{on•Fee:$.,129:00: ; or• IhcompleGe will:lie;n'e'turrie{i:
Please type or print and complete all information
# of Units: Address:, b`' \-6cn L w Ldp City; Newport Baach State: CA Zip: -1
PropeRyOwner: �'`, v\ r t ivN4 Zip Code:.
Owner Address:j%5 \ /� Qty: N �Q� `�°i�.cy)
State; Zip Code: " I L�j �1 Home Phone: I Gf Lj_q . 7,7, 0 ' 0 7*i
Owner's Authorized Agent; t Work Phone: / e
Agent Address: vb U "s y. Ity:�•
state:) Zip Code: Zl! Agent Emall Address:
Escrow Company: S Escrow #:I Ulm
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Escrow Address: City:— on < —J
State: Zip Code: Escrow Ph -1
Email Report to: Wyl
For Inspection call (Name): Direct Phone:
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELOW)
PavtProrize lnspectrons.andre-ii'spection's'of'the property listed above. I undersla:ridthat.if B;u.hding•erZonlhg.
viblationsare.discovered] nviil:M:respansibl'e.to correctsai'd viblitrDns.
Owner/Aient''ssignature•to•authenrze•rnspectibn: Date:.
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Owner/Agent'ssignaturetodecirne.lnspecGron: _ �''�'��` Dater •��
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Account # 010SOSO4-521040 .................Make checks payable to: Cr7Y OF NEWPORT BEACH
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