HomeMy WebLinkAboutR2021-0177 - Permit ApplicationCity, mfNewport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
1U0Civic Center Drive |P.O.Box 1768|Newport Beach, [X\Q2G5D-DQi5
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
4ofUnits: Address:
Please type or print and complete all information
City: State: Zip:
vroperty0vxne,:1- F7777
Z]pCode
Owner Address: iCity:
State: ' Z]p�ode� Home Phone:
Owner's Authorized Agent:
Work Phone:
Agent Address: 64
i ury:|__
State: FTi�i Zip Code: FCF1 Agent Email Address:
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Escrow Company: Escrow #:
Escrow Address:
State: Zip Code: Escrow Phone:
Email Report to: | T')\)(L'' cc) rl |
For Inspection call (Name): Direct Phone:
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELOW)
I authorize inspections and re-inspectionsof the property listeclabove. I understand,thatif Building or Zoning
violations are discovered Iwill be responsible to correct said violations.
Owner/Agent's signature to authorize inspection: Date: F-
c OR
Own er/Agent's signature to decline inspection: Date: s/
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