HomeMy WebLinkAboutR2021-0176 - Permit ApplicationForm City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA92658-8915
www.newportbeachca.gov 1 (949) 644-3200
Application for Report of Residential Building Records
Application Feer -$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
# of Units: F Address: isw U,4: City: [New State: FCA i, Zip:Fq:�-?l
Property Owner. Zip Code:
N-,QAr\A-" City:
Owner Address:
State: Zip Code: Home Phone:
Owner's Authorized Agent: Work Phone:
Agent Address:
G+�V4.c--N- city: 7-5
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State:F7&,-F-- Zip Code: FS-- Agent Email Address: 17
Escrow Company: Escrow #:
Escrow Address: Jr- City:
Zip Code: Escrow Phone: t3l-� LLAL[
State: FTT-1 c�--DQ, Li(--): I
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Email Report to: \D P aD c -A- 3\j--,,�3P�--ekcAamcscmu, "w�
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 un
violations are discovered I will be responsible to correct said violations.
owner/Agent's signature to authorize inspection:
owner/Agent's signatureto decline inspection:
Account # 01050504-521040 ................. Make Y
Building _01v1s1an\Forms\RBR 7-3020
id that if Building or Zoning
Date:
Date:
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Davable to: CITY OF NEWPORTBEACH